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roperly <br /> ' .Applications will Be Processed When SubAPtPeLiCATIQNpleted. Be Sure <br /> l <br /> (For Non-Transferable,Re4ocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE /J I <br /> Applicatlo is here y d to carry bu in s in the jurisdictional area of the n J uin Loc I He District <br /> 7 Addr ss <br /> NBusiness a (DBA) Address <br /> aOwner f / <br /> J Firm Partners, Addresses and Telephone Numbers a Emergency Telephone No. p� <br /> 0. Business Telephone No. <br /> Contractor Licence No. I Date <br /> ` Title j <br /> Applicants Name (Print) <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) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Gal.,Weights &.Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 w <br /> No. of Vehicles Stored <br /> I No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST - R.S. or R.C.E. No. <br /> E R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. SANITATION PERMIT <br /> r <br /> Job Address/Locption Address y7`3 <br /> i Owner111�9 11 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACK GE PLANT _ <br /> ❑ SEPTIC TANK 11CESSPOOL ❑ NEW 13 REPAIR ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> � Disposal Site <br /> Type Construction <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> • Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE. ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> r ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> r I hereby certify that l have prepared this appli tion an that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r nd re latio o the an Joaquin Local Health District. <br /> k APPLICANT'S SIGNATURE <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT ;"❑ PER SITE [I EACH [3 January l &Received By January 31 ❑ July 1 &neceiveRdElMITuVy 3t f <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> L" FEE VIN <br /> <'J <br /> F LESS <br /> PRORATION <br /> PLUS <br /> r PENALTY <br /> OTHER <br /> OTHER <br /> Date Receipt No. Permit No, <br /> Issuan Date Mailed Delivered <br /> _ Received by 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />