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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign IneAppncauL011. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ereb made to carry o busiraeS 'n the jurisd�tkojnarea of the an Joaqu'n Local Heal Distric <br /> yBusiness Na a (DBA) ddres <br /> a Owner <br /> Y Address <br /> Firm Partners, Addresses and ep one_Numbers <br /> Emergency Telephone No. <br /> a. Business Telephone No. <br /> Contractor Licence No. io <br /> Date <br /> L Applicants Name (Print) `� _Title <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) <br /> Serial No. CAL. License No. GAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 S <br /> No. of Vehicles Stored U3 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location <br /> Test Date/Time �i <br /> 4. SANITATION PERF41T <br /> Job Address/Location 3 e 3 �P 'h o o C'�n�✓" S r <br /> Address <br /> Owner G �" " <br /> Owner C3 PACKAGE PLANT <br /> � <br /> L'�'SEPTIC TANK 13 CESSPOOL <br /> Q.e�CHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> B-PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR , <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 y� <br /> Type Construction <br /> Disposal Site ~ <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 i t <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> 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 /> ❑ 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 iaws, an rules nd re ions otj)e�an Jo qui Local He th District.- <br /> �r <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT IKPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 ' <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> LAS' a/ <br /> FEE _ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> a 0 <br /> Issua <br /> Received ate Receipt No. Permit No. ce Qate Mailed Qelive d <br /> 1601 E.KAZELTON AVE.,P.O.Box 2909 STOC ON,C 95201 <br /> APPLI ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> TA <br />