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1 rt Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> •` _ APPLICATION <br /> (For Non-Transferable,,evocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to garty on busiss in t e}uri dictional area of.the San Joaquin Local Health District <br /> yBusiness Name (D } V Addres <br /> aOwner Address _ - <br /> 0 Firm Partners, Addresses and Telephone Numbers z. p <br /> CL <br /> Business Telephone NO., Emergency Telephone No. <br /> Contractor Licence No. ` <br /> L Applicants Name{Print) Title Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) v <br /> For July 1, June 30, 19 L Disposal Sites _ - - - <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. r <br /> Capacity Gat.,Weights &Measures No. <br /> Equipment Parking Address '— E <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 /> TestLL ion Test Date/Time <br /> 4. V&SANITATION PERMIT <br /> Job Address/L ation <br /> Ow r * Address ff©ly <br /> eez <br /> i <br /> LR SEPTIC TANK ❑ CESSPOOL 9 LEACHING FIELD _ S PAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 11 NEW L"l REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> F <br /> Type Construction Disposal Site <br /> O <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 r <br /> Plant Location 11 <br /> Plant Capacity _ No. Units Served``- <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 -� �. . ;:`,,� t 11 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ 'More Than 1,000 Sq. Ft. ,. �f f <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 rul and regul tions- f theSan Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY .x <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 /> RASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT '\ <br /> FEE 48 ¢ <br /> LESS ` <br /> PRORATION <br /> PLUS ` <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3(oa l <br /> Received by Date Receipt No Permit No. Is uance ate I Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES `1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />