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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 /> i ? ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br />,i Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) _yCf�Gl1 Address �� <br /> aOwner_ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Q. Business Telephone No. 3 Emergency Telephone No. <br /> _j Contractor Licence No. <br /> LApplicants Name (Print) Titlef 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 /> k <br /> Serial!No. " CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. 01 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> k <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 hocation Test Date/Time <br /> 4. �I SANITATION PERMIT <br /> Job Address/Location <br /> I Owner —ate&& 3 CA--,w PJ&L Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ;4 SEEPAGE PIT_ ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> I <br /> Type:Construction Disposal Site Or <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 8. 0 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> r Operator Name Where Certified y <br /> Planth 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 /> II + <br /> Il 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 regulation the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 4. FOR DEPARTMENT USE ONLY <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31, ❑ July 1 &Received By July 31 <br /> Y <br /> IREMIT <br /> BASEEXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> ado <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUSPENALTY <br /> OTHER jI <br /> OTHER <br /> Received by Date - Receipt No. Permit No. Issuancif Date Mailed Delivered <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bol 2009- STOCKTON,CA 95201 <br /> t I� <br />