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compieteo <br /> Applications Will Be Processed When Submitted Properly <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE 1 <br /> j; ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> I Applicata is h reby ode to carryon busi ss in the jurisdictional area of the n Jo in Local Health District f <br /> Address <br /> rBusiness Name (DBA) <br /> Address <br /> aOwner " <br /> J Firm Partners, Addresses and.Tele hone mbers _ Emergency Telephone No. <br /> ! a Business Telephone No. <br /> Contractor Licence No. Title Date <br /> E LApplicants Name (Print) <br /> Please check Applicable Category,(1-7)and Fill in the Required Information lQ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, JDisposal Sites <br /> 30, 19 p V) <br /> Description(Make/Yr., Color) CAL, License Renewal No. <br /> I <br /> Serial No. CAL. License 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 r <br /> No. of Chemical Toilets Stored <br /> g. 1:1PERCOLATION TEST it R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. j2T SANITATION PERMIT <br /> I Job Address/Loc tion +✓ . <br /> ! rry�ll Address <br /> 13 P0 <br /> Owner <br /> <] CESSPOOL lye LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT V <br /> SEPTIC TANK ❑ REPAIR ❑ OTHER <br /> PERMANENT ❑ TEMPORARY 25 NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> t Type Construction Disposal Site <br /> -a !i. Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> g. ❑ PACKAGE TREATMENT-'PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> N. <br /> Plant Location rg <br /> No. Units Served <br /> Plant Capacity <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 /> II T <br /> 1 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 r es and regulations o the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> I Z5/g3t5 <br /> . �vin S rINL <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> July 1 &Received July 31 <br /> Fee Is Due: (3 ANNUALLY.. <br /> ❑ PER UNIT El PER SITE C1 EACH ❑ January 1 &Received By January 31 ❑ REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ' BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> c ys�a <br /> FEE <br /> i LESS <br /> PRORATION <br /> [, PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ! <br /> 47,r7 <br /> Received by <br /> r,Date Receipt Na. Permit No _ Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE,,P.O.Box 2099 STgCKTON,CA 9520 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />