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Applications Will Be Processed When SubbmiitPL�CAT�ONPleted. Besure toaiyn •+rr <br /> Properly c`• - '� <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> } . LIQUID WASTE <br /> Application i reby�Tadocarry o busin�Ad <br /> urisdictional area of the jan Joaquin Healthy is�trir t l <br /> Address <br /> Business Name (DBA} ess <br /> i Owner <br /> a <br /> Firm Partners, Addresses and Telephone,Numbers Emergency Telephone No. <br /> i <br /> aBusiness Telephone No. �� : <br /> Contractor Licence No. Date 'f <br /> a <br /> {' Title h <br /> Applicants Name (Print) <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 ` <br /> Description(Make/Yr., Color) CAL. Lioznse Renewal No. 11 <br /> Serial No. CAL. License No. `� <br /> Gal.,Weights & Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> E 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 /> 4 R.S. or R.C.E. Name Test Date/Time <br /> 4 Test LKation <br /> 4. L'a SANITATION PERMIT <br /> Job Address/ cation < IeU <br /> Owner Address <br /> L ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT Dj <br /> ' !E'STIC CP <br /> ❑ CESSPO L ❑ REpAIR ❑ OTHER <br /> 111PERMANENT ❑ TEMPORARY `N <br /> 5.' ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction <br /> Disposal Site r <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, '19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> I 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ruip and regulations of he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due'. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> I PRORATION <br /> f PLUS <br /> PENALTY r <br /> I OTHER <br /> {I OTHER <br /> ' - lasua ce to Mailed Delivered <br /> Date Receipt No. Permit o. 09 STOCKTON,CA 95201 <br /> Received by 1601 E.HAZELTON AVE.,P.O.Box 20 <br /> ` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />