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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> �� APPLICATION <br /> V (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application/1�.�e�re y madrt�p carryon business in the jurisdictional area of the San Joaquin LocaLHealth District ,( <br /> ,,Business Name ,DBA) ! IL x` / _ Address A. <br /> i Owner t% L/' Address >,G �>r� 2fc <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> 9 _ <br /> Contractor Licence No. <br /> L Applicants Name (Print) '` ' ` Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information I <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 i / <br /> /{° ' " `/ Address <br /> Owner s-f-�h - /, ,../ Sj—�- <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> W�PZRMANENT ❑ TEMPORARY -NEW ZREPAIR ❑ OTHER (�1 <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 h7�rule <br /> red thi application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and r ulatio the Sa Joaquin 1,,ocal Health 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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER At 1 <br /> � o IT-1 a�.� ��i I � <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />