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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) <br /> �j ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> t !/� LIQUID WASTE <br /> Application i hereby m de to,carry n busir�ess'n the isdictional area of the Sa JoaIn Local Health D'strict <br /> FBusiness.Nafi�e BA) Address /=�T �— <br /> z Owner ~ Address <br /> JFirm Partners, Addresses and elephone Numbers <br /> t a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. Z Z <br /> L Applicants Name (Print) Title Date ��' -.P/ <br /> Please check Applicable Category (1-7) and Fill in the Required Information �( <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) OU <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Llcz;nse Renewal No. <br /> 1' Capacity Gai., Weights &Measures No. <br /> Equipment Parking Address <br /> I 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> F <br /> No. of Vehicles Stored <br /> h No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.0 E. Name R.S. or R.C.E. No. <br /> Test L ation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Loc ion <br /> Owner A Address—a';–'g �� �•a � �� � � <br /> ❑ SEPTIC TANK CESSPOO EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW PAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> f 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 /> f 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 es and regulations f the San Joaquin Local Health District. <br /> I <br /> i APPLICANT'S SIGNATURE X <br /> f <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 $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 5 <br /> LESS ) 1 <br /> PRORATION <br /> PLUS /t <br /> PENALTY <br /> OTHER <br /> OTHER f <br /> i <br /> +- Received by Date Receipt No. Permit No. Issua ce Datk Mailed- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL.HEALTH PERMIT/SERVICES 1601 E.HAZELTON.AVE.,PA.Box 2009 .STOCKTON,CA 95201 <br />