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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION ' <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby mj#de 4Darry QA business in the jurisdictional area of the San Joaquin Local Healt District B <br />+ m Business a (DBA) Add ess <br /> z Owner Address " <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No.rSw <br /> Contractor Licence No. � <br /> Applicants Name (Print) Q�� Elf- Title bGc3.c5� Date <br /> I 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 <br /> I Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity GaL, Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> h No. of Chemical Toilets Stored <br /> f 3. ❑ PERCOLATION TEST r <br /> k R.S. or R.C.E. Name R.S. or R.C.E. No. �^3 <br /> Test Lo ation Test Date/Time <br /> 4. L`7 SANITATION PERMIT _ � <br /> Job Address/Location -� �' 0 _ 11 0 <br /> Owner . <br /> Address <br /> LrSEPTiC TANK ❑ CESSPOOL OILEACHING FIELD Q-12EPAGE PIT ❑ PACKAGE PLANT { <br /> RIPERMANENT ❑ TEMPORARY 2<EW ❑ REPAIR ❑ OTHER <br /> + 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units _ Equipment Storage/Cleaning Location(s) <br /> ' <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> {k Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this app' ation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a es a regulat s f t San Joaquin Local Health District. <br /> ' APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> 4 Fee Is Due:.❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED A OUNT <br /> FEE <br /> LESS <br /> 1 PRORATION <br /> j PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> `� . 1 <br /> Received by bate Receipt No. P r it No. issuance Date Mailed Delivered <br /> A 'APPLICANT—RETURN ALL COPIES TOF- ENVIRONMENTAL HEALTH PERMITISERVICES � 1fi01 E.'RAZELTON AYE.;P.O.Bo - 0>�09 _ STOCKTDN,�95201 <br />