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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 HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry.on busin ss i th jurisdictional area of the San Joaquin Lpcal He Ith District <br /> 1R Business Name Address Z <br /> aOwner Address CdL4fdV' ' <br /> Firm Partners, Addresses and Telephone Numbers ¢ <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LAppiicants 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) r <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 <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 Lac ion —_ Test Date/Time <br /> 4. SANITATION PERMIT r, <br /> Job Address/Location �1"a <br /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR `OTHER A,9AA1AV <br /> &4,^l <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 F 0 <br /> Operator Name WhereCertified <br /> r – <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 /> 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 rules and r gulatio p of th n Joaquin 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 i3 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> { AMOUNT <br /> FEE \ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY D <br /> OTHER <br /> OTHER <br /> U LO <br /> 76 <br /> i <br /> ReWed ed by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.Q,Box 2009 STOCKTON,CA 95201 — <br />