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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 4M j T (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> 'f ENVIRONMENTAL HEALTH PERMIT <br /> K I LIQUID WASTE �j <br /> Applicati hereb ade rry on bu�jess in the jurisdictional area oft San Joaqui Local Healt District <br /> ,F Business Name {DBA) �'�1i}S_ �.L� . _ Address <br /> aOwner Address <br /> Firm Partners, Addresses and T I p one NLLMbers <br /> a. Business Telephone-No. T Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) S 0,44SWA 'Title Dater— <br /> Please check Applicable Category (1-7)and Fill in the Required Information y <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) y� <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 /> 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 �1 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. ti <br /> Test Location Test Date/Mime <br /> 4. XSANITATION PE211,9 r <br /> Job Addre /Location <br /> t <br /> Owner '14 Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL XLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT , <br /> $k-PERMANENT ❑ TEMPORARY ❑ NEW `REPAIR '.OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site r <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. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. w r <br /> I hereby certify that I have prepared this a plicati an hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules f the n aquin al Health District. <br /> APPLICANT'S SIGNATUREX <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 tl <br /> .1 REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED , <br /> _/ �� AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> 4 <br /> PLUS <br /> PENALTr,--. <br /> IfI` <br /> OTHER <br /> T <br /> OTHER <br /> r . <br /> Received by Date Receipt No: r Permit No. i' I5 uance p to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMIT/SERVICES r+ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />