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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,ind Su spendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in•the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA)_+,J $ idoV tJ��N��� - Address <br /> i Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No: Emergency Telephone No l't <br /> Contractor Licence No. .. <br /> Applicants Name (Pring ® Title Rate; V 1 <br /> Please check Applicable Category (1-7)and Fill in the Required Information 4 y <br /> t 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. <br /> Test Location Test Date/Time g <br /> 4.-9SANITATION PERMIT <br /> Job Address/Location :-42 <br /> F <br /> er Address <br /> EPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARY VEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, 7 June 30, 19 . ' F <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 - <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 4 - <br /> SIZE: - ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> f - <br /> I hereby certify that 1 have prepared this application and that the work will tie done in accordance with San Joaquin County <br /> ordinances, state laws, rules and regulations of the J u ealth District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY w _ <br /> r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE - ❑ EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31 -..x <br /> REMIT <br /> BASE EXPLANATION BILLING 'REMITTANCE - $ AMOUNT DUE CHECKED <br /> - 4 - DATE DATE REMITTED AMOUNT <br /> l FEE <br /> 5 <br /> E LESS <br />` PRORATION <br /> PLUS <br /> -PENALTY - "- - - - <br /> OTHER rt � <br /> OTHER <br /> i I <br /> Received by I Date, I i 116celkol 14o.I Permit No. I5 ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br /> k` <br />