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4tions Will Be Processed When Submitted Properly Completed. BeSureTo SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable;Reliocable,and Suspendable) / SEPTAGE <br /> ENVIRONMENTAL HEALTH4PERMIT 6 <br /> of LIQUID WASTE <br /> /Application is h y made to ca ry on b iness in the jurisdictional area of t an.Joaquin LocHeh i trict - <br /> me (DBA) Address y •.� <br /> .+F •. -Address. <br /> eartners, Addresses and Teleo e Num ers u <br /> siness.Telephone No. �? Emergency Telephone No. <br /> o ltractor Licence No. <br /> Applicants Name (Print) Title <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) <br /> Serial No. CAL. License No. j. CAL. License Renewal No.'- r <br /> r Capacity Gal.,'Weights &Measures No. <br /> Equipment Parking Address ._ . . <br /> 2. ❑ PUMPER YARD ,y <br /> For July 1, June 30';19 r-.. <br /> No. of Vehicles Stored - _ <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST fQ <br /> R.S. or R.C.E. Name R.S.or A.C:E. No. t <br /> Test Location Test Date/Time" i } <br /> 4. 9 SANITATION PERMIT f� <br /> Job Address ovation <br /> Owner .)&V Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD KSEEPAGE PIT ❑ PACKAGE PLANT <br /> 11PERMANENT [] TEMPORARY NEW Jai REPAIR 0 OTHER I <br /> r 5. ❑ CHEMICAL TOILETS For July 1, =June 30, 19 <br /> Type Construction• r Disposal Site <br /> No. of Units Equipment Storage/Cleaning'Location(s) ( x <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,;June 30, 19 <br /> { Operator Name � �; (__Where Certified <br /> Plant Location <br /> Plant Capacity t No. Units Served r <br /> 7. El LAUNDRY For July 1, -June 30, 19 __ s,a.- <br /> SIZE: Q Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. " <br /> ❑ DRY CLEANING, Chemicals Used/Amount,1 . <br /> r I hereby certify that,I-have prepared this application and that the work will.be done iri accordance with San Joaquin County. ' <br /> ordinances, state laws,,and rules and regulat ns aft art.Jo in Local Health District. <br /> -APPLICANT'S SIGNATURE X <br /> t <br /> FOR DEPARTMENT USE ONLY __ <br /> 1 <br /> Fee Is Due: ❑ ANNUALLY _❑ PER'UNIT ❑ PER SITE ❑ EACH _❑ .fanuary 1&Received By January 31 ❑ July 1 &Received By July-31 <br /> REMIT <br /> BASE EXPLANATION ] BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> . '� ., .+.•�-+«_.,.��...:,.:•..;,, �..- -,�Lt- DATEATE. .. REMITTED .�•. - AMOUNT <br /> FEE <br /> { <br /> € <br /> LESS N <br /> PRORATION : l ' <br /> - v <br /> PLUS <br /> PENALTY - --I - •_-- <br /> OTHER i r <br /> OTHER <br /> t f t F <br /> Received by Date 4!�? Receipt No Permit No. f Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.13ox 2009 STOCKTON,CA852 i <br /> fj JJ/ <br />