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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) SEPTAGE <br /> ENVIRONMENTAL HEALT_ H;PERMIT " <br /> r 1 LIQUID WASTE <br /> Appl ication i ereby ma to carry o business i he jurisdictional area of the Joa In Local Health Distri <br /> [-Business N e (DBA) ddress_ 76 2 <br /> a <br /> z Owner Address <br /> a ti .- <br /> J Firm Partners, Addresses and Telephone Nu hers <br /> 4 Business Telephone No: ,Emergency Telephone No <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Ca gory -7) and,;;ill in'the equired Information ; <br /> I. ❑ PUMPER VEHICLE ERM REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 9 Disposal Sites - <br /> _- <br /> Description(Make/Yr., Color) f <br /> Serial No. CAL. License No. CAL. License Renewal No. . t—1 <br /> r. Capacity Gal.,Weights & Measures.No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ' ., <br /> For Juiy 1, June 30, 19 <br /> ` No:of Vehicles Stored' <br /> No. of Chemical Toilets Stored t <br /> 3. '❑ PERCOLATION TEST , ' k , <br /> R.S. or R.C.E. Name R.S. or R.C.t'N-o.'. t. <br /> Test Location Test Date/Time a <br /> *. 4. ❑ SANITATION PERMIT " - } J] /� w T � _'e�~{ { <br /> Job Address/Location <br /> Owner AddressAW <br /> I� PTIC TANK ❑ CESSP OL ,Q, LCHING FIELD SEEPAGE PIT PACKAGE PLANT <br /> L V PERMANENT E] TEMPORARY NEW ❑ REPAIR ❑ OTHER S <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t <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 ` <br /> Operator Name Where Certified <br /> Plant Location I <br /> r 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 /> Italian*ora d+peFut1jeittLjW rkmal C:'r"eeiolJjiauni%"Lm ertifyttrIt�thefleftm MeOf the Work forwhichtmspermkisissoed,I$hall�notern n a <br /> ti1SB6t11�tatlRer as tel becolhe Sil!sle4t to t�rorkman':;.c�a'r(>r;C7ti::�!:IF;',°:s`„0aS1.,a, r] P°I Y 1tYDeySttr► <br /> Coetraater'a Kiri r <br /> or vu`rrrm?-8r ting sir�ny;;r.: tifi� , �w�n�. certe ti.21 in i;ic per%prmance ;the tion for which t!!;t'perrrti is tssut�,f shall <br /> employ persons pj[Gi to wor,Jtraci s co:ny�c:;s�.i�i,law,,lit i�a;cr',:,d.' <br /> - <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 es an ulatiorls of the a in Local Health District. <br /> APPLICANT'S SIGNATURE X : <br /> - - — FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ., ❑-PER UNIT' ❑ PER SITE . ❑ EACH ❑ January-1.&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BELLING REMITTANCE $ <br /> ' BASE EXPLANATION - AMOUNT E CHECKED / <br /> DATE DATE REMITTED p AMOUNT <br /> FEE .'� <br /> LESS <br /> PRORATION <br /> PLUS <br /> 9 <br /> PENALTY - - --- - <br /> i OTHER <br /> OTHER <br /> pi e— * 'M!�e I- <br /> eceived by Date Receipt No' - - Permit No Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />