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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> _ <br /> J�o <br /> (For Non-Transferable, Revocable,and Suspendable) / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT [ <br /> LIQUIO WASTE <br /> Application is hereby made tocarryon business in the jurisdictional area of San aquin Local Health District <br /> rn Business Name (DBA} Address <br /> z Owner _ <br /> a Address <br /> Firm Partners, Addresses and Telephone Numbers ° - <br /> aBusiness Telephone No.. — Emergency Telephone No. <br /> Contractor Licence No. . <br /> 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) <br /> For July 1, June 30, 19 Disposal'Sites <br /> Description(Make/Yr., Color) .. <br /> Serial No. I CAL. License No. CAL. License Renewal No. <br /> Capacity '_ Gal., Weights& Measures No. <br /> Equipment Parking Address ti <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 /> Test cation Test Date/Time <br /> 4. SANITATION PERMIT 5 s <br /> Job Address/Location <br /> fnOer <br /> EL Address <br /> PTICTANK ❑ CESSPOOL ❑ LEACHING FIELD C1SEEPAGE PIT 13PACKAGE PLANT ERMANENT ❑ TEMPORARY ❑ NEW REPAIR 11OTHER CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction - Disposal Site ' <br /> No. of Units Equipment Storage/Cleaning Locatian(s)'- r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> 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.' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> �l��hi � t?>; s <br /> rafii�`stlbjict to arorfim 1' I°'��'s�s,�+'f'�rfh�manuev'ft�retY,.�,s �.�,• 3 <br /> Xy1etsaa�s�n�t'��`Ia�r;?iiitrYcttt�h Kietn�:�orn{iLi�rri�. � ,I,,zl ��i•:: t��ltt�sit�SESSl,,�44tit�ll�gttF� '�Qrs <br /> t P i)jeri tff r ;r err=�a 1 �.�r,� I ;� ct[tre�vnflc;fvr • <br /> tiUJf;�i%h?1.��7T4i�tli 1Tr os '„�r,,�is::,.4,.,,i�.. �. ” •rr:''•F:t.i+i the erfn.rinance �fhi�h,lttrs ' <br /> ,� '.11i�11tltits i��tLtiQ,lls�lE <br /> i hereby certify that I ha�rb]prepared this application an hat the work will be done in accordance with San Joaquin County r' t <br /> ordinances, state laws, a ules and re ations of the n Joal�iin 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 Juiy 31 <br /> BILLING JTTANCE REMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> DATEMITTED AMOUNT <br /> FEELESS ��PRORATIONPLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receivedby Date Receipt No. Permit No. IssuancLa 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 />