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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio s h reby m to c ry on bloiness in the jurisdictional area of the San Joaquin Localealth i <br /> yBusiness N e (DB ) Address. Q <br /> z Owner Address <br /> Q L <br /> J-Firm Partner , Addresses and Tele one Numbers <br /> Business Telephone No. G Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) _ -d Title Date <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. CAL. License Renewal No. <br /> Capacity Gal., Weights & 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 /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. �t <br /> �i <br /> Test Location Test Date/Time (� <br /> 4. ❑ SANITATION PERMIT _` \� <br /> Job Addre ocation �/ 1� <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL X LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE 46LANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW gREPAIR OTHER—V L P <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site - <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified R 3 <br />� Plant Location <br /> 0 <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq, Ft. <br /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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, les and re ula cons of the i n Joaquin Local Health District. I <br /> 1 n <br /> APPLICANT'S SIGNATURE X j <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY- ❑ PER UNIT ❑ PER S1TE ❑ EACH ❑ .January &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 57 <br /> w <br /> LESS F` – <br />( PRORATION <br /> PLUS <br /> t PENALTY <br /> t OTHER 006 <br /> f OTHER ..4 <br /> �. oa0000 <br /> Received by Date Receipt No. Permit No Issuance Date Mailed eliv ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERViCES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOQkTON,CA 15201 <br />