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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> I (For Non-Transferabte, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to a_r�on busine the jUri dictional area of the—San Joaquin Local Health Dis rict «, <br /> yBusiness Name (DBA) — [� 1r�_; � � t -�1 Address <br /> z Owner _= 1L� Address <br /> a - - - s <br /> J Firm Partners, Addresses a T I hone Nulnbe - <br />�.. a Business Telephone No. I s Emergency Telephone No. <br /> a <br /> Contractor L-icence.No-- *•- p� <br /> L Applicants Name (Print) Title <br /> Please check Applicable Category 1-7 and Fill in the Required Information E <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; June 30, 19 Disposal"Sites w... <br /> Description(Make/Yr., Color) _ <br /> Serial No. CAL. License No. f CAL:License <br /> _Renewal No. <br /> `Capacity "'Gal"'Weights`&-Memores`No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> _ <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST �F <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> k Test Location Test Date/Time <br /> f 4. ❑ SANITATION PERMIT a <br /> Job Addr Location <br /> Owner Address r l I <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD -SEEPAGE PIT 11 PACKAGE PLANT ; <br /> c <br /> ❑ PERMANENT TEMPORARY 1111 .OTHER N£W � �. REPAIR � <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 f <br /> Type Construction Disposal Site_ -- ' <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> &. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 i <br /> Operator Name ( --Where Certified— .- E <br /> Plant Location I I <br /> Plant Capacity No. Units Served i ' [[[ <br /> 7. ❑ LAUNDRY For July 1, -.June 30, 19 ~' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. } m <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certifythat --ha prepartthis.applicationand that the wofk'will be done in"accordance with San Joaquin County <br /> ordinances, tate�1awsnSd",rm;,,ljes an re of +3 San oaqu' Local Health District. n <br /> I APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLYf i a <br />! Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 4111 EACH ❑January 1 &Received By January 31 ❑ July 1 &Received By July 311 ¢ <br /> - - <br /> BILLING REMITTANCEs REMIT <br /> $ 4 <br /> BASE EXPLANATION DATE - DAT , ` - REMITTED AMOUNT DUE AMOUNT ..�- <br /> 8 <br /> FEE <br /> LESS ) <br /> PRORATION <br /> PLUS # <br /> PENALTY <br /> � I <br /> OTHER - <br /> OTHER <br /> Received by i I Date 'Receipt No Permit No. Issuance Date i ,Mailed Delivered <br /> STOCKTONCA 95201 <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O,Bol 2009 ; <br />