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V Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. I <br /> Y APPLICATION y <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on b siness in the jurisdictional area of the_aaan)oagf in Local Health District <br /> F Business Name (DBA) _J• �� rr L Address [[��F".,464, <br /> _ <br /> cr <br /> r �- Address2 �'�� G <br /> a Owner '" <br /> Firm Partners, Addresses and Telephoners _ <br /> CL <br /> It Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. �` Date <br /> f 4 <br /> L Applicants Name (Print) <br /> Title ��'� t <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. 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 F :. <br /> No. of Vehicles"Stored <br /> No. of Chemical Toilets Stored �1 <br /> 3. ❑ PERCOLATION TEST `^ <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location' Test Date/Time . t <br /> 4. ❑ SANITATION PERMIT - -C . <br /> Job Address/Location <br /> OwnerL L Address <br /> 11r� SEPTiC TANK ❑ CESSPOOLEAC <br /> HING FIELD 11 SEEPAGE PIT <br /> 11 PACKAGE PLANT - <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 11 REPAIR ❑ OTHER. k _ <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 w k <br /> Where Certified _ <br /> Operator Name ',,f <br /> Plant Location !7 _- <br /> Plant Capacity <br /> 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. R <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 0 <br /> I hereby certify that I have prepared this application fand.that the work will be done in accordance with'San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE' 0 EACH ❑ January 1 &Received By January 31"Y ❑ July 1 &ReceivedREMITuVy 31 <br /> BASE EXPLANATION BILLING > REMITTANCE $ AMOUNT DUE CHECKED <br /> DATES DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 4 OTHER <br /> OTHER ti <br /> [ Recei by - Date - Receipt No. Permit No. u e Date Mailed Delivered <br /> i , APPLICANT—RETURN ALL COPIES TOE ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />