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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applica, <br /> APPLICATION q r <br /> &1 0 (For Non-Transferable, Revocable,and Suspendable) [ ` SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 3 " <br /> Applicationi re made car�r,on siness in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (PBA) _ �"� � �_�' Address <br /> i Owner ���' � Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> r <br /> Applicants Name (Print) �'' Title l`" Date = _ <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) <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 /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT _ <br /> Job Address/Location " �rc-� <br /> rrO��wner "�- -4J'0 _ Address .-._.-j"1�"kms <br /> O-SEPTIC TANK ❑ CESSPOOL t A HING FIELD EPAGE PIT 11 PACKAGE PLANT <br /> 44 PERMANENT 13 TEMPORARY ,_,i3--NEW EPAIR ❑ 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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> 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 a d t applic and that t e work wi1F be done in accordance with San Joaquin County <br /> ordinances,state laws,�bAel n gulat' the San J uin Loc ealth District. <br /> APPLICANT'S SIGNATURE X <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 /> BILLING REMITTANCE $ REMIT <br /> . BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE. , dAA 4q <br /> 5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY f <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. rssuahce ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON A Box 2009 STOCKTON,CA 95201 <br />