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1 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,'-Revocable,and Suspendable) SEPTAGE <br /> ` ENVIRONMENTAL HEALTWPERMIT <br /> LIQUID WASTE <br /> Application is he <br /> y b m�ade to caonbuse�ss theiurisdictional•area of the n in Local al Distri t <br /> v 'Business Name (DBA) .., <br /> y" <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numrs <br /> aBusiness-Telephone No. ;2 r J Emergency Telephone No.. <br /> Contractor Licence No. <br /> Applicants Name (Print) t�l1VY- l Title _ _-Date <br /> i J <br /> 1 Please check Applicable Category 0-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACHVEHICLE) <br /> g� <br /> For July 1 r June 30,19'L ,' - =Disposal Sites - - <br /> Descriptio,(Make/Yr.., Color) <br /> Serial No CAL. License No/tJ CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> I, <br /> EquipmentParking Address. <br /> 2. ❑ PUMPER YARD 'YT ww <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored f <br /> 3. ❑-PERCOLATION TEST <br /> `s <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> = � - <br /> k Test LL ation Test Date/Time 11 "4 <br /> 4. L?f SANITATION PERT�-3I <br /> Job Address! cation _ S ' <br /> 4 Ow�r joldS Address 'e- ` ) <br /> ISI SEPTIC TANK ❑ CESSPOOL MILLEACHING FIELD ❑ SEEPAGE PIT; ❑rPACKAGE PLANT. <br /> ❑ PERMANENT 13TEMPORARY ❑ NEW - ❑ REPAIR 6T.HER <br /> t <br /> _ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 #� "`,• <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 a <br /> Operator Name - Where Certified — <br /> Plant Location __ <br /> Plant Capacity No Units Served <br /> 1 7. ❑ LAUNDRY For July 1, -June 30,19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., Q More Than 1,000 Sq. Ft. t ! <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 9 , <br /> ' r , <br /> hereby Certify that I have prepared this application and at the work will be done in accordance with San Joaquin County <br /> _ ordinances, state laws, and_rules and regu _•ons of the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE-X od <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER 4 NIT'; ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juty 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE K <br /> LESS <br /> PRORATION r �r <br /> II PWS <br /> i PENALTY <br /> f <br /> OTHER <br /> OTHER _ y <br /> / <br /> I! _ Z6 <br /> O a 63 G 1ST 3 <br /> 4, Received by Date Receipt No. Permit No. WS a ate Mailed Delivered <br /> F` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ' STOCKTON,CA 95201 <br />