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rApplications Will Be Processed When Submitted Properly Completed. BeSureTosign tineHppin-al—ii. <br /> APPLICATION <br /> 3=�] (For Non-Transferable, Revocable, and Suspendable) SEPTAGE G <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ,• Od'�Z 5' r USA:�13/�G'�_�y�tJE ., LIQUID WASTE �-perp CQ � <br /> � 2 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> to Business NaTe (DBA) <br /> z Owner, Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> CL Business Telephone No. <br /> 4 -31 <br /> Contractor Licence No. <br /> Title R — Date <br /> Applicants Name (Print) <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) CAL. License Renewal No. <br /> Serial No. CAL. License No. - <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD _ y <br /> For July 1, June 30, 19 N, <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E. No. N <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT F _ <br /> Job Address/Location 0�E'J/y z)6 E <br /> i Address G <br /> Owner ❑ PACKAGE PLANT <br /> ba SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> ® PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIRS _ w Q <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 "1 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Clean iinngLo :atitio�n(s) <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,,19 <br /> Where Certified <br /> Operator Name - <br /> Plant 1-6cation _ <br /> " '�§No. Units Served <br /> Plant Capacity <br /> 1 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 les an regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> �k <br /> ! FOR DEPARTMENT USE ONLY <br /> ❑ ❑ PER UNIT El PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee IS Due: ANNUALLY <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 731 <br /> Permit No Issuance DateReceipt <br /> c7 Issuance Date Mailed Delivered <br /> Receipt No. <br /> Received by - 1601 E.HA2ELTON AVE.,P.O.Box 2004 STOGKTON,CA 95207 <br /> i APPLICANT—RETURN ALL COPIES TO:� ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />