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a Applications Will Be Processed When Submitted Properly Completed. BeSure o <br /> APPLICATION <br /> . _ (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica ion is hereby made to car on bust s in the I risdictional area of the Saq J�oaquin�Local Health Dist <br /> Address <br /> yBusiness Name (DBA) <br /> aOwner = Address <br /> 2 Firm Partners, Addresses an Telephone Numbers Emergency Telephone No. <br /> C6 Business Telephone No. <br /> k Contractor Licence No. Title ate F <br /> `` Applicants Name (Print) ~ <br /> i Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1: ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> t For July 1, June 30, i9 Disposal Sites ' <br /> _71 <br /> Description(Make/Yr., Color) <br /> CAL. License No. <. CAL. License Renewal No- _ - <br /> Serial No. <br /> s &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 /> R 3. ❑ PERCOLATION TEST . <br /> " R.S. or,R.C.E.No. A <br /> r R.S. or R.C.E. Name '' K <br /> Test Date/Time _ <br /> Test Location <br /> a4b` 0_ SANITATION PERMIT <br /> I Job Ad ess/Location t� ' <br /> O ner Address, <br /> ❑_LEACHING FIELDSEEPAGE PIT 0 PACKAGE PLANT- <br /> SEPTIC TANK ❑ CESSPOOL ❑ OTHER <br /> PERMANENT ❑ TEMPORARY NEW REPAIR <br /> 4� r„ <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 A. <br /> I ;. '"'"'Disposal`SiteT" <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> ti <br /> 5. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> y <br /> Plant Location <br /> - No. Units Served <br /> Plant Capacity _ <br /> 7:--E3-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/Amoun&MO. <br /> I herebycert if at I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I <br /> ordinances, st to la and riule nd regulat ns of the Sa Joaquin Local Health District. <br /> F <br /> APPLICANT'S SIGNATURE ` <br /> FF <br /> 1 / <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER.UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 B ReceivedREMIT 31 <br /> ' BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE - DATE REMITTED AMOUNT <br /> FEE <br /> LESS t <br /> PRORATION <br /> f PLUS <br /> ( PENALTY <br /> f OTHER <br /> OTHER <br /> 77 q— Z a <br /> Date Receipt Na Permit No. Issuance Dae Mailed Delivered <br /> Received by 1- 1601 E.HA2ELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br /> APPLICANT-RETURN ALL COPIES 1 0: -ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />