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Appiicalions Will Be Processed When Submitted Properly APPLICATIONpleted. Be sure 10algn 111W^rr•�- <br /> ,�. (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT ! <br /> LIQUID WASTE <br /> Applicatiolereby r�rlade t c rry.on b siness in the juri fictional area of the 5aaquin Local Health Dista i <br /> I A dress <br /> wBusiness Name v Address <br /> aOwner I <br /> Firm Partners, Addresses arid,Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. or <br /> Contractor Licence No.Contractor Date <br /> CJ`t <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information r lj <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l/ <br /> For July 1, June 30, 19 Disposal Sites ; <br /> Description(Make/Yr.,Color) CAL. License No. CAL, License Renewal No. <br /> 1 <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity � <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 R.S. or R.C.E. No. <br /> R*S' <br /> or R.C.E. Name Test Date/Time <br /> Test Dation <br /> 4, lJ SANITATION PERMIT Q ' <br /> Job Add re* Location 7 Z <br /> Address <br /> Owner ❑ LEACHING FIELD ❑ SEEPAGE PlT ❑ PACKA PLANT <br /> ❑ SEPTIC TANK ❑ C S POOL ❑ REPAIR ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site aG <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 Where Certified <br /> f Operator Name <br /> 4 <br /> Plant Location No. Units Served <br /> f Plant Capacity <br /> II 7. ❑ LAUNDRY For July 1, -June 30,19More Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> 4 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 rulesX3 regulations o e an loaquin Local Health District. <br /> APPLICANT'S SIGNATURE X C(�1 <br /> I <br /> I <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv July 31 <br /> REMIT <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS / <br /> PRORATION <br /> I PLUS f <br /> r+ PENALTY <br /> ` OTHER <br /> t <br /> I OTHER (/`iI Gf � f} 4/J�� w�y� <br /> L V <br /> l ' Permit No I suanc Date Mailed Delivered <br /> l 01 <br /> Date Receipt No. <br /> Received by- 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON;CA 952 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM <br />