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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 /> Application i ere by made carry on business in theuris fictional area of the San Joaquin Local Health District 1 <br /> oBusiness Name (D ) �--•� Address ®� " �L {• <br /> Ownere�� Address S . <br /> Firm Partners, Addresses and Telephone Numbers -" - <br /> Business Telephone No. <br /> 36 8 S/0 5 �T' 1� Emergency Telephone No. '^ <br /> Contractor Licence No. ZZF 1 <br /> Applicants Name(Print) Title -' Date <br /> Please check Applicable Category 0-7) 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. Lic:.nse 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 4 <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test L ation Test Date/Time 1 <br /> 0. SANITATION PERMIT <br /> Job Address/Location <br /> Ow er Address ye •''�`'`~� <br /> PTIC TANK ❑ CESSPOOL 1.L?ACHING FIELD T ❑ PACKAGE PLANT (n <br /> lQf PERMANENT I� TEMPORARY ;NEW El REPAIR ❑ OTHER <br /> 6. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 a <br /> Type Construction Disposal Site <br /> Equipment Storage/Cleaning Location(O <br /> No.of Units � <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 rule and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X — A A X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT [I MR SITE ❑ EACH ❑ January 1 8 Receivetl By January 31, ❑ July 1 &ReceN RBy EMITuly 31 <br /> SASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED I AMOUNT <br /> FEE J <br /> I LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 a a— I r-n/1 Cly- <br /> Receivetl 6y Date Receipt No. Permit NO <br /> I arae eta Malletl Deliveretl <br /> STOCKTON,U P52a1 <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1eM E.HAZELTON AVE.,P.O.Baa 2009. � ' <br />