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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. } <br /> t -' a APPLICATION 1 <br /> .L' (For Nan=Transferable,Revocable, and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> LIQUID WASTE <br /> Application i ereby mad to carry on usiness ir�the' isdictional area of the Sa oa uin Local Health Di tri ict- } <br /> J & _ <br /> �Business Name i3A) _• Address ; <br /> I z pwner Address <br /> E Q <br /> j Firni'Partners, Addresses and Telephone Numbers <br /> Business Telephone No. g 510 Emergency Telephone No. <br /> 'Contractor Licence No. 2Z <br /> �Applicants Name (Print) Title Date <br /> E Please check Applicable Category (1-7) and Fill in the Required �ormafion <br /> ; <br /> 1. ❑ PUMPER-VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) e <br /> Serial No: CRL. License No. CAL. License Renewal No. <br /> Capacity, s� s Gal.,Weights &Measures No. <br /> Equipment Parking Address ._ <br /> 2. ❑ PUMPER YARD <br /> For.July 1, June 30, 19 <br /> p No. of Vehicles Stored <br />{ No. of Chemical Toilets Stored <br /> t 3. ❑ PERCOLATION TEST r <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time t <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner _ Address <br /> 11 SEPTIC TANK E] CESSPOOL ❑ LEACHING FIELD 13 <br /> PLANT <br /> C3 PERMANENT ❑ TEMPORARY 11 NEW } I ❑ OTHER <br /> r <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, <br /> Type Construction Disposal Site I <br /> No, of Units Equipment Storage/Cleaning Location(s) : <br /> 6. ❑ PACKAGE TREATMENT PLANT ForvJuly June 30, 19 t <br /> Operator Name Where Certified <br /> L Plant Location <br /> No. Units Served t `' <br /> Plant Capacity - .�. o <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. / <br /> J# r <br /> I 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 rules an regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> f <br /> r#, 1 <br /> 3 FOR DEPARTMENT USE ONLY <br /> ' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 & ived By July 31 <br /> - - - REMIT "' <br /> I BILLING REMITTANCE j $ AMO CHECKED <br /> BASE EXPLANATION DATE DATE RE TTED - <br /> �- AMOUNT <br /> FEE x14 q S-- <br /> r <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> (9 OTHER <br /> OTHER <br /> Received by Date Receipt No. Perrhit No. issuance u,a[e Mailed Delivered <br /> -APPLICANT—RETURN ALL COPIES to: ENVIRONMENTAL HEALTH PERMLT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 96201 �� <br />