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Applications Will Be Processed When Submitted Properly Completed. BeSureTosign ineAppncauvn. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ' reby�n�de to r on bus ess in e- ri ctional area of the San uin oc Health District <br /> Business Name ) Address <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers—11 <br /> a Business Telephone No. �� ,� Emergency Telephone No. <br /> a <br /> Contractor Licence No. Date <br /> LApplicants Name (Print) Title <br /> Please check Applicable Calegory (i-7) and�Fillthe Required formation p , <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. 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.gar R.G.E. Name R.S. or R.C.E. No. <br /> TestkL ttion Test Date/Time r , <br /> q, IA SANITATION PERMITe/ <br /> Jab Address/Local _ <br /> Owe Address <br /> LF7 SEPTIC TA K ❑ ❑ PACKAGE PLANT <br /> CESSPOOLCHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY & NEW ❑ REPAIR <br /> 5. ,❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction <br /> No. of Units ^+� Equipment Storage/Cleaning Location(s) } <br /> �+ c <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ; <br /> Operator Name Where Certified <br /> Plant Location <br /> ' No. Units Served <br /> Plant Capacity <br /> 7.j11 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 /> 1 <br /> Ihereby-certify that I have prepared this application and that'the work will be doneiri`accordance with San Joaquin County <br /> ordinakes, state laws, and rules a regulatioris of the San Joaquin Local Health District. <br /> --�'-- <br /> APPLICANT'S SIGNATURE X �y 4 <br /> ' FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> -DATE REWTTED^- — AMOUNT <br /> ar <br /> LESS <br /> PRORATION i <br /> i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No- Permit No. ssu ce ate Mailed Delivered <br /> _ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boll 2009 STOCKTON,CA 9520 <br />