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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 0 <br /> �r ENVIRONMENTAL HEALTH PERMIT J <br /> LIQUID WASTE <br /> Application is hereby made to c3Ayon business in the jurisdictional area of the San Joaquin L al He District <br /> „r, Business Name (DBA) Address ' 1 Gi <br /> zOwners Addresses <br /> Firm Partners, Addresses an Telephone Numbers <br /> aBusiness Telephone No. —, ,�Z b 9 Emergency Telephone No. <br /> Contractor Licence No. <br /> a �� Title -�l �'�-� Date ?== <br /> �Applicants Name (Pring <br /> Please check Applicable Category (1-7) and Fill Ii 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. a <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/ cation PERMIT <br /> V/ / <br /> Owner_ y J—C�,,r 42, Address <br /> 11SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ElPACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR 0 OTHER A4A1U00 V <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 <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 /> �r <br /> I hereby certify that I have prepared this lication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state I n les and re latio s 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 ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE <br /> BASE EXPLANATION DATE DATE REMITTED 'AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> s <br /> LESS /p- <br /> PRORATION i r <br /> PLUSSn ,/ic f C a." <br /> - <br /> PENALTY //'� <br /> OTHER f <br /> OTHER <br /> Received by ate Receipt N6. Perm <br /> Mailed <br /> Delivered- <br /> APPLfCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />