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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> x APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE I' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made toil rry o usil int e ju isd' tional area of the J� �Local Health District <br /> OF Business Name (DBA) '` Addresses <br /> z Owner Address <br /> a - <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> CL Z~ Emergency Telephone No. <br /> EL Business Telephone No. t <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date Q' <br /> Please check Applicable Category(1-7)and Fill In the Required Into ation <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. 11 PUMPER YARD, s M•y� "? j <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored ` f <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 - �—r� ^""`�""`"' t-Daty e T m <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Locati n <br /> r . <br /> Owner Address F v. <br /> © SEPTIC TANKI ❑ CESSPO'CL_ E CHiNG FIEtLD iT ❑ P CKAGE PLANT N <br /> tA <br /> ❑ PERMANENT ❑ TEMPORARY ❑-NEW .04-t�.�.� REPAIRj_j ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 N <br /> t <br /> Type Construction Disposal Site ! <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> IF <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name I' - Where Certified <br /> Plant Location ( ` <br /> Plant Capacity No. Units Served F <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. i <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 an Llations of the-San J aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is-Due: ❑ ANNUALLY ❑ PER UNIT 11 PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT. <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS _ <br /> PENALTY <br /> OTHER i <br /> OTHER ' <br /> /V// e <br /> Received by '-Date Receipt No. - Perm+t No. Issuance Dale ai �Del <br /> APPLICANT—RETURN ALL COPIES-TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.-HAZELTON AVE.,P. x 2009 STOCKTON,CA 95201 <br />