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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ° APPLICATION <br /> i (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> =' LIQUIO WASTE <br /> Application Is eb ade t arry on bu mess in the uri ictional area of the San Joaquin Local Health Dislnc <br /> F Business Name DBA)/_t U r " « Address r <br /> aOwner G> -•C�_ �' Address /low <br /> Firm Partners, Addresses and Telephone Numbers <br /> r M Business Telephone No. � �2 / >✓ Emergency Telephone No. <br /> Contractor Licence No. �E� l <br /> Applicants Name (Print) A Title - Date Z <br /> Please check Applicable Category (1-7)and Fill in the Required Information i <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. SXSANITATION PERMIT <br /> Job Address/Location Il _R� - �d <br /> Ownerie.ol �G� `� Address <br /> 11SEPTIC TANK 11CESSPOOL J:Y-tEACHING FIELD A4 <br /> _EEPAGE PIT ❑ PACKAGE PLANT <br /> -PERMANENT ElTEMPORARY El NEW �iEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For'July 1, -June 30, 19 <br />' Type Construction 11 Disposal Site <br /> k No. of Units Equipment Storage/Cleaning Location(s) <br /> t 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> f 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 1 have prepared t is ap ' tion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, anan ion of a San Jo Lin Local Health District. <br /> f ' <br /> APPLICANT'S SIGNATURE J. <br /> FOR DEPARTMENT USE ONLY <br /> F Fee Is Due: ❑ ANNUALLY d ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By.July 31 <br /> BILLING REMITTANCE $ REMIT <br /> EXPLANATION AMOUNT DUE CHECKED <br /> BASE <br /> DATE- DATE REMITTED AMOUNT <br /> , <br /> FEE C�j li _ S <br /> LESS <br /> i PRORATION <br /> : PLUS .fy <br /> PENALTY- / <br /> OTHER r' r <br /> t OTHER o <br /> t Received by Date Receipt No. Pe i No Issuance Da Maile ehvered <br /> m <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELT AV ,P.D.Box 2009 - STOCKTON,C 1 <br /> A r- <br />