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., <br /> .Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. l <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application reby made to carry on b-usl ess in the jurisdictional area of the San Joaquin Local Health District <br /> Business Na A) ��7 <br /> �` Address ° <br /> a Owner <br /> Address <br /> J Firm Partners, Addresses and Tel h�Num5er, <br /> IL Business Telephone No. `— -��,� Emergency Telephone No. <br /> Contractor Licence No. d°,r� _-e-? � <br /> Applicants Name (Print) ® Title <br /> Date <br /> / <br /> Please check Applicable Category (1-7)and Fill in the Required Information �— 7 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> i <br /> CAL. License No. GAL. License Renewal No. <br /> Serial No, I <br /> Capacity Gal.,Weights &Measures No. I <br /> Equipment Parking Address ` <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored j <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.GE. Name R.S. or R.C.E. No. <br /> Test Date/Time <br /> Test Location t <br /> 4. '� SANITATION PERMIT r <br /> Job Address/ cation <br /> Owner <br /> Address SEPTIC TAN ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT <br /> 11 PACKAGE PLANT Cd <br /> PERMANENT 11 TEMPORARY _LEACHING <br /> ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 /> 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 applicatioh and that the work will be done in accordance with San Joaquin County - <br /> i ordinances, state laws, an e d regulations-6f the San Joaquin ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑-January 1 &Received By,lanuary31 ❑ July 1 &ReceivedREMIT 31 <br /> F BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - DATE DATE REMITTED AMOUNT <br /> FEE �� <br /> LESS <br /> PRORATION <br /> ` <br /> i PLUS <br /> PENALTY <br /> OTHER ` <br /> OTHER <br /> 4�ba & - ISI � a <br /> I Received by <br /> Vale Receipt No. Permit No. y Issuanc at ailed Delivered <br /> APPLICANT—RETURN ALL COPIES-TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZEL .,P.O.Boz 2009 S70CKTON,GA 95201 <br />