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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) r <br /> SEPTAGE <br /> L�Z'I1 ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> Application i hereby made to car on business in the-jurisdictional area of the San Joaquin Local Health District, <br /> Business Name (DBA) Address <br /> a Owner-_ Address <br /> i � <br /> Firm Partners, Addresses and Telephone Numb rs �L�1 <br /> aBusiness Telephone No. � Emergency Telephone No.- <br /> Contractor Licence No. <br /> LApplicants Name (Print) �ie �cfL Title - - Date <br /> ' Please check Applicable Category(1-7)and Fill in the Required Information <br /> ' 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For July 1, . June 30, 19 _ Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No, CAL. License Renewal No. r <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/Tire <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 14P 4,44z7-A <br /> Ow r Address t <br /> 'SEPTIC TANK ❑ CESSPOOL IKLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 1,} <br /> ❑ PERMANENT ❑ TEMPORARY. •,- 111 NEW 11REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1 -'June 30, 19 S <br /> Type Construction Disposal Site <br /> jNo. 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 t <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 �.. ., ►- " =-` <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft=z <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared this application and=that.the work will be done in accordance with San Joaquin'County f <br /> ordinances,state laws, and rules and la ' of the Joaquin;Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT'.USE.ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SIT.E ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received.By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING MITTANCE: $ AMOUNT DUE CHECKED I <br /> .. DATE DATE REMITTED AMOUNT <br /> FEE _ j1 <br /> 48�� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> i J <br /> -OTHER <br /> Received by Date Receipt No. Permit No, Issu nce ate. g, Mailed Delivered <br /> .-tom �.r.., <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HR2ELTaR'A2009 STOCKTON,CA 95201 <br />