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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 business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name- (DBA) Address . <br /> aOwner_ L1_,._.�4L VA Address <br /> ��..... <br /> Firm Partners, Addresses hd Telephone Numbers y 3 <br /> a. Business Telephone No. Emergency Teiephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) 4 vzoz 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. 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 Location Test Date/Time <br /> 4. %SANITATION PERMIT <br /> Job Address/Location G <br /> Owner Address <br /> 19 SEPTIC TANK ❑ CESSPOOL I. LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 1I NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site v <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r <br /> Operator Name 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 /> I hereby certify that I have prepared this application an,04hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, o rules and regulations of the n oaquin LI Health District. <br /> APPLICANT'S SIGNATUREX <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT - <br /> FEE 7_7 <br /> LESS <br /> PRORATION I j Y 8 I�� <br /> I 1 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> IVOTHER �J <br /> [ D C1 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivd <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGer ON,CA 9 201 <br /> 1 <br />