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Applications Will Be Processed When Submitted Properly Completed.Bsure iozl 1TRY ; <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application 's her by m to arty on sine s' the jurisdictional Aadraressthe Sydoaqui ocal Health Dist ct <br /> y Business N (DBA) <br /> G Address a' <br /> aOwner 7y - <br /> jrm <br /> Firm Partners, Addresses and Telephone Numbers 3 <br /> �l 3 3 Emergency Telephone No. i <br /> IL <br /> Business Telephone No. <br /> Contractor Licence No. Title Date <br /> Applicants Name (Print) c '' <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites 9 <br /> Description(Make/Yr., Color) l <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address t <br /> 2. ❑ PUMPER YARD _ <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S.or R.G.E. No. ° <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. QrSANITATION PERMI S� <br /> Job Addres Location <br /> Owner L•� y Address ❑ PACKAGE PLANT <br /> UYSEPTIC TANK ❑ CESSPOOL gi LEACHING FIELD 9;-SEEPAGE PIT <br /> iI,,_, 11 REPAIR ❑ OTHER � <br /> fsrYERMANENT - 1:1 TEMPORARY �Elllf cn <br /> §. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) M <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> i Plant Location <br /> No. Units Served p <br /> Plant Capacity [/kk <br /> 7, ❑ LAUNDRY For July 1, -June 30, 19 �T <br /> SIZE; ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. n <br /> t <br /> f <br /> I hereby certify that I have p d this app ti n and that the work will be done in accordance with San Joaquin County <br /> F ordinances, state laws, a rule nd regulat' San Joaquin Local Health District. <br /> 1 APPLICANT'S SIGNATURE X <br /> ` FOR DEPARTMENT USE ONLY <br /> 'Fee IS Due: ❑ ANNUALLY PER UNIT F-1 PE SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received <br /> By J }y 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED MOUN <br /> k 4 ��a <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> '"�-- Permit No issuance Date Mailed Delivered - <br /> -"Received by' Date Receipt No. - <br /> "�TUI. <br /> APPLICANT—RETURN'ALL-COPIESENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 35201 � <br />