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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 i hereby ma to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Nam (DBA) � �� Address <br /> i Owner w >_ Address <br /> a - <br /> j Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ��`-�2 z o Emergency Telephone No. <br /> Contractor Licence No. =3G_ <br /> Applicants Name (Print) Titley 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 PERIT <br /> Job Address/Locatio ��' � I �' � <br /> Owner �- <br /> N�z e, ,r Address <br /> ✓SEPTIC TANK ❑ CESSPOOL OLEACHJNG FIELD _SEEPAGE PIT ❑'+;'PACKAGE PLANT <br /> -� PERMANENT ❑ TEMPORARY NEW-. ❑ REPAIR ❑ OTHER 4; <br /> 5. 0 CHEMICAL TOILETS For July l,-' June 30, 19 d <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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r d regul ions o he San Joaquin Local 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 /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED � <br /> Q DATE DATE REMITTED AMOUNT <br /> FEE `� S <br /> LESS <br /> PRORATION' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> cz <br /> Received by Date Receipt No. Permit No. Is,suanco Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,-CA 95201 <br />