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. * <br /> Applications Will Be Processed When Submitted Properly Completed. Be <br /> APPLICATION <br /> ry (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �i LIQUID WASTE <br /> Application is ere y made to car mon business in the jurisdictional area of the San o quin Local Health District <br /> rBusiness Name (DBA) '~ Address <br /> Q Address <br /> a Owner <br /> Firm Partners, Addresses and Telephone Numbs <br />$ Business Telephone No. Emergency Telephone�No. <br /> Contractor Licence No. I, <br /> Applicants Name (Print) <br /> :rt - Title Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> N. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 1_ <br /> For July 1, June 30, 19 4 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No, CAL. License No. <br /> Capacity ' Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> n � <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 �I <br /> No. of Vehicles Stored `' 11 - <br /> No. of Chemical Toilets Stored IL <br /> 3. ❑ PERCOLATION TEST <br /> I R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name s+6: <br /> �. 4 Test-Date/Time-� <br /> Test Location. <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location -- 07? y GHQ <br /> Owner — Address <br /> © SEPTIC TANK C3 CESSPOOL 13 LEACHING FIELD ❑ SEEPAGEfPIT -0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR l] 'OTHERI, <br /> 5.-❑ CHEMICAL TOILETS For July 1,-June 30, 19 a M <br /> Type Construction � D'tsposal,Site""""'°" "" <br /> No. of Units Equipment Storage/Cleaning Location(s) a I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19r <br /> "11V" here Certified <br /> Operator Name : f <br /> Plant Location �^ <br /> li <br /> Plant Capacity No. Units Served <br /> � <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft,, ❑ More Than 1,000 Sq, Ft. 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> II <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with an Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />`. APPLICANT'S SIGNATURE X I" } <br /> FOR DEPARTMENT USE ONLY _ <br /> I .I <br />). Fee IS Due:,❑ ANNUALLY_❑ PER UNIT ❑ PER SITE - ❑ EACH �_0 January 1_&Received;By January 31 ❑ Jufy t &Received 31 <br /> -YI-~ ~BILLING REMITTANCE k ,�.M`�. AMOUNT DUE GNECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> , <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I OTHER <br /> i � Daie'. Receipt No. Permit No. - ' Issuance Date Ma'ded -Delivered <br /> -Received by ,y <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON.AVE.;P.O.6ox2009 STOCKTON,CA-95201 <br />