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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 /> Appl ication is h r ,made to caTry on business in the jurisdictional area of the San Joaquin Local Health District <br /> C. Business Nam DBA) / - Address -,�,� t <br /> Owner :.r Address <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. n Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) ��' TitleDq <br /> Date <br /> Please check Applicable Category (1-7)and,Fill in the Required Information <br /> 1. C] PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For July 1, June 30, 19 Disposal Sites - - _ - <br /> Description(Make/Yr., Color) LA <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> .Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address . <br /> 2. ❑ PUMPER YARD <br /> -For July 1, June 30, 19 r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT ^I <br /> Job Address/Location 0 <br /> Owner , Address C <br /> ❑ SEPTIC TANK 11 CESSPOOL Xg-LEACHING FIELD GkEEPAGE PIT ❑ PACKAGE PLANT <br /> C_/PERMANENT ❑ TEMPORARY '®_NEW GIS-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 /> Operator Name Where Certified :5 <br /> Plant Location °n <br /> Plant Capacity No. Units Served 91 <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 /> F. <br /> - I hereby certify that I have prepar this ppl' tion d that he work will be done in accordance with San Joaquin County <br /> ordinances, state.laws, and rules and ��,bran aquin Lo 'Health District. <br /> APPLICANT'S SIGNATURE'X —' <br /> - FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ FA ❑ January1 8 Received By January 31 ❑ July 1 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> EASE EXPLANATION . DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br />' PENALTY <br /> OTHER. <br /> .OTHER <br /> a <br /> Received by Date Receipt No Permit No.. Issuance Date Mailed De ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ' <br />