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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheAppllcallon. <br /> APPLICATION <br /> ..._�„. (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the n Jo uin Local Healt District <br /> ,Business Name (DBA) Address <br /> aOwner Address 3) <br /> Firm Partners, Addresses and Telephone Numbers 0r <br /> d ��— D Emergency Telephone No. <br /> 0. Business Telephone No. } <br /> a <br /> Contractor Licence No. ?_7 Ire) <br /> L Applicants Name (Print) — 1 S Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I 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 /> I 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 <br /> L° on Test Date/Time <br /> 4. �J SANITATION PERMIT 1C <br /> Job Address/Location 3 O <br /> /j'J/ � /Lf/ Address ` <br /> Owner ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT <br /> 13 PERMANENT ❑ TEMPORARY ❑ NEW 2 REPAIR ��E ����� 1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> 14 Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TRE=ATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> I <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 accordance with San Joaquin County <br /> t ordinances, state laws, d rules an regulation f the- Jo uin-Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due-. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received ByJanuary31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ 'AMOUNT DUE CHECKED <br /> .. DATE DATE REMITTED AMOUNT <br /> �:. <br /> FEE <br /> LESS <br /> PRORATION <br /> I PLUS <br /> y PENALTY <br /> kk OTHER <br /> - OTHER <br /> os as say <br /> i Received ey - Date Receipt No- Permit Nro Issuance Date Mailed Delivere <br /> I APPLICANT—RETURN ALL COPIES TO:, ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> f <br />