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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 1 v 'R <br /> .� APPLICATION -o, <br /> 9Ls <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGEENVIRONMENTAL HEALTH PERMIT <br /> LIQUIQ WASTEX <br /> Applimade to'carry OR business in the jurisdictional area of the San Joaquin LOW Heal t i ict <br /> FBusiness Name (DBA Address <br /> I a Owner Address <br /> J Firm Partners;Addresses and Telephone NumbersCL - <br /> CL Business Telephone No. Emergency Telephone No. <br /> I Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Catego 6 (14) and FIII in the Requir Information <br /> r. 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,'19, Disposal Sites <br /> rs Description(Make/Yr., Color) -'t'�"*� <br /> Serial No.. CAL. License No. � w - CAL' License Renewal No. r <br /> Capacity - Gal., Weights & Measures No. _ 0 - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD s <br /> F�- . � <br /> k` For July 1, 1 i June 30,19 <br /> Nol'of*,N e_hicles-Storedtz> <br /> No. of Chemical Toilets Stored � <br /> 3. El'PERCOLATION TEST <br /> R.S_or R.C.E. Name-* _ p'1�'R.§ or 9.-C.E6.. -� <br /> "-s <br /> Test Location,' Test Date/Time...- -- <br /> 4. ❑ SANITATION PERMIT " <br /> Job Address/Location.. .. t_ _ <br /> Owner dress <br /> SEPTIC TANK ❑ CE SPOOL LEACHING FIELD ❑ 7 '❑ PACKAGE°PLANT <br /> ERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> 4, <br /> 5. ❑ CHEMICAL TOILETS For July 1, -J e 30, 19� <br /> Type Construction Disposal Site . <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �r <br /> Operator Name — - Where Certified <br /> Plant Location <br /> Plant Capacity <br /> - 4 No. Units Served <br /> - <br /> 7. F-1Capacity <br /> For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than'',000 Sq. F`'. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared this application rand that the work will.�e done in accordance with San�loaquin County <br /> ordinances, state laws, and ruleAs and regu ons of th -San Joaqui ocall Health District <br /> } <br /> E APPLICANT'S SIGNATU X 1 ) <br /> _ _ LJ U Lia <br /> 3 FOR DEPARTMENT USE O LY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT [I PER 517E ❑ EACH' J n ar 1 &Received By January 31 ❑ July 1 &Received By July 31 ? <br /> REMIT 4 <br /> BASE EXPLANATION BILLING ANCE $ AMOUNT DUE CHECKED - li <br /> DATE AT <br /> REMITTED AMOUNT <br /> FEE <br /> LESS . <br /> PRORATION <br /> PLUS _ <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> R peived by•- Date- Receipt No, Permil No. I suance Date� Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: EN YIRONMEN_TA_L-HEALTH PERMIT/SERVICES ��*1601 E.HAZELTON AYE P.O.Be.2009- STOCKTDN;'CA 95201 ;' <br />