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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> - W (For Nan-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application/js h eby ri t arry on business in the jurisdictional area of the San Joag.Uin Local Health District <br /> Address Z C <br /> FBusiness Name (DBA) �� P�� <br /> z Owner Address -� - —t <br /> I1-7 <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. y Emergency Telephone No. <br /> -J Contractor Licence No. <br /> L Applicants Name (Print)_ 1L/ Lc� Title 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) 1 <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 /> j R.S. or R.C.E. Name - ^ R.S. or R.C.E. No. <br /> � <br /> Test Location Test Date/Time <br /> 4, If SANITATION PERMIT z ` <br /> Job Address/Location <br /> Owner Address <br /> EI SEPTIC TANK ❑ CESSPOOL 6 LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT <br /> 4. 'PERMANENT ❑ TEMPORARY — ❑ NEW mm ❑iREPAtR �[a OTFiERi. <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30; 19 <br /> Type Construction Disposal Site <br /> I No. of Units Equipment Storage/Cleaning Location(s) S <br /> 1 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> No. Units Served. <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,01)0 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. . <br /> h I hereby certify that I have preparRd this application and-that the work will be done in accordance with San q tC <br /> ordinances, state laws, and rules and re lauon of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY - <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1-&Received By January 31 -❑ July 1 &Received By July 31 <br /> REMIT <br /> 1 BILLING, REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE',/` DATE ~'REMITTED AMOUNT <br /> r <br /> FEE �. <br /> 1 LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> t Received by Date Receipt No. Permit No:,_. Issuance ate Mailed Delivered <br /> i <br /> -APPLICANT—RETIl ALL COPIES TO: :ENVIRONMENTAL HEALTH PEAMITISERYkCE5,5;. - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />