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�. Applications Will Be Processed When Submitted Property Completed. Be Sure.To Sign The Application. <br /> APPLICATION <br /> O (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio 's hereby ma a to carry on�t Isme sin the jur dictional area of the San Joa um Local Health Di ct <br /> Business Name BA) Address <br /> z Owner Address - <br /> 4 <br /> Firm Partners, Addresses and Telephone Nufnbers <br /> a Business Telephone No. S�aJ� Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Dale 2-�s�kz <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> C 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 /> F Equipment Parking Address <br /> l 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> r. No. of Vehicles Stored <br /> No. of Chemical Toilets Stared <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test LL tion Test Date/Time <br /> 4. v SANITATION PERMIT �� � <br /> Job Address/ cation . <br /> - _�r✓ ✓ Address <br /> OE SPTIC TANK 11 CESSPOOL LkLEACHING FIELD T ❑ PACKAGE PLANT <br /> El-"PERMANENT ❑ TEMPORARY ❑ NEW UTREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 a <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 accor09nce with San my <br /> ordinances, state laws, and rules regulations of th n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X G <br /> ti FOR DEPARTMENT USE ONLY If1 <br /> ti <br /> Fee IS Dile: 13 ANNUALLY El PER UNIT ❑ PER SITE C1 EACH ❑ January 1 &Received By January 31 -❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING l REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE !U <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t -- <br /> OTHER <br /> f Received by Date Receipt No. Permit No. fIssua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O:.Boa 2009 STOCKTON,CA 95291 <br />