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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - z APPLICATION <br /> (For Non-Transferable,"Revocable,'and Suspendable) SEPTAGE <br /> �- ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area.of the San Joaquin Local Health District <br /> FBusiness Name (DBA) —Address j - <br /> z Owner <br /> a Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) wr 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 - y <br /> Description(Make/Yr., Color) <br /> Serial No. i CAL. License No. . . s CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No, <br /> Equipment'Patking Address_ <br /> 2. ❑ PUMPER YARD 4 <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.G.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location.. !S �?� <br /> r Address <br /> EPTIC TANK ❑`CESSPOOL '0 LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR 11 OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site V) <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location t f - <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 /> 0 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> l/ <br /> Az <br /> I hereby certify that I have preparedlthis application and;that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the an Joaquin Local Health District. <br /> 1 <br /> APPLICANT'S SIGNATURE X <br /> " <br /> if - FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31• ❑ July 1 &Received By July 31 <br /> '+'BILLING REMITTANCE $ REMIT <br /> BASE - EXPLANATION AMOUNT DUE CHECKED 't <br /> DATE DATE REMITTED AMOUNT <br /> FEE /fC <br /> LESS <br /> PRORATION <br /> PLUS y`y <br /> PENALTY <br /> OTHER r <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance D 16 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 -STOCKTON,CA 952 <br />