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s Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TneAppucallOn. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) 1 <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio hereby map to carry busines Int jurisdictional area of the Sa Joaquin Local Health District <br /> o � Address��� � <br /> F-Business Name BA)• <br /> z Owner Address_ # <br /> a <br /> Firm Partners, Addresses an Telephone Numbers <br /> CL Business Telephone No. ®.S Emergency Telephone No. <br /> Contractor Licence No. � <br /> LApplicants Name (Print) <br /> Title Date my <br /> Please check Applicable Category�((1-7) the Require Intormation 1 <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. <br /> CAL. License No. CAL. Lic.nse Renewal No— T <br /> Capacity Gal., Weights & Measures No, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> r <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored f <br /> No. of Chemical Toilets Stored i <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/lime <br /> Test Location <br /> q, 09"SANITATION PERMIT <br /> j� �L' <br /> Job Addre / cation�' -�'S 46 t7 0OwneAddress❑ SEPTIC TANK POOL ❑ LEACHING FIELD �� PAGE PIT ❑ PACKAGE PLAINT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW I FtE AIR ❑ OTHER � <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> l Type Construction Disposal Site <br /> f No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> $ Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> j 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> f SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. w <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> N <br /> i <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 s and regulations a an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY . <br /> - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEMIIT By my 31 <br /> rl <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> }i c E DATE DATE REMITTED AMOUNT FEE 4S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> h <br /> OTHER <br /> 1 -3qLS 101 <br /> Receipt No. Permit No Issuan Date Mailed Delivered <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.BOK 2004 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />