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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 /> I LIQUID WASTE <br /> C " i <br /> I Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District ; <br /> I y Business Name (DBA) ,ri�/r/yp/Yy � '�' Address po, die, no/arrd C.I. Qf"7S'3 <br />'• z Owner Address <br /> Q <br /> Firm Partners, Addresses and Telephone Numbers <br /> I a Business Telephone No. .S�a 3- `'� Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title, Date <br /> 1 ; <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 /> I Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal. Weights &Measures No. <br /> Equipment Parking Address <br /> i 2. ❑ PUMPER YARD t <br /> For July 1, - June 30, 19 <br /> No. of Vehicles Stored I <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 /> I Test Location Test Date/Time <br /> F 4. 0 SANITATION PERMIT, <br /> Job Address/Location <br /> '4o FiY/�4.f/ 70 �`.0dYS Address es -6^� )4-' '''��� <br /> Owner <br /> 0 SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 9 PERMANENT ❑ TEMPORARY ® NEW ❑ REPAIR ❑ 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 /> t Plant Location <br /> !I Plant Capacity No. Units Served <br /> ! ' 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> I 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 /> iordinances, state laws,and rul s and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> t Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑.January 1 &Received By January 31 ❑ July 1&_Received By July 31 <br /> REMIT <br /> I BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATEREMITTED AMOUNT <br /> FEE _ - <br /> LESS <br /> PRORATION <br /> PLUS <br /> ` PENALTY. <br /> OTHER a/ . <br /> e <br /> OTHER a' <br /> Received by Date Receipt No.- Permit No.. Issuance Date Marled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 95201 <br />