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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION V ' ` -` <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ���✓✓✓ LIQUID WASTE <br /> Application,I�hereby maadd-e'to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) /I/ 4o ! Address <br /> aOwner l �� � Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �— 5771 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) ,�Y ��cn Title ?°u 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 Toilet&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 /> t+ Job Address/Location <br /> t Owner ` Y/✓1 Addressr` <br /> ❑ SEPTIC TANK ❑ CESSPOOL OLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW Z-14EEk1R- , ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30:19 <br /> Type Construction f 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 Y t <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 rules and re Iat' sof th San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY Q PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January,31 ❑ July 1 &Received By July 31 <br /> _.__. REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ 4h40l NIT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATIONPLUS <br /> F <br /> PENALTY <br /> OTHER r <br /> OTHER - -,- <br /> Received by Date Receipt No. Permit No. suanceD Mailed Delivered <br /> APPLICANT—A@TURN}`gt l COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON O.Box 2009 STOCKTON,C <br />