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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transterable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> AppIicati ereby to arry n business in the jurisdictional area of the San Joaquin Local Health Di 'ct /r <br /> yBusiness Na ( BA) Address <br /> z Owner Address 4e X40 IS: <br /> d <br /> 7 Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. "��, _ Emergency Telephone No. <br /> Q ; <br /> Contractor Licence No. <br /> Applicants Name (Print) Title_ Date <br /> Please check Applicable Category(1- and Fill 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. License Renewal No. i <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. or R.C.E. Name R.S. or R.C.E. No. <br /> Test ocation Test Date/Time ' <br /> , 4. P SANITATION PERMIT, <br /> Q <br /> Job AddreA�ation r <br /> Owner Address(.- <br /> ❑ SEPTI ❑ ESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAG LANT <br /> PERMANENT ❑ TEMPORARY 11NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS ForJuly 1,-June 30, 19 � <br /> Type Construction -Disposal Site f <br /> I <br /> No. of Units Equipment Storage/Cleaning Location(s) f <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Where Certified <br /> Plant Location _. I <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19— <br /> SIZE: <br /> 9 .SIZE: ❑ Less Than 1,000 Sq. Ft., ❑.More Than 1,000 Sq. Ft. ! <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. . <br /> k <br /> I hereby certify that I have prepared this application and that the worklivill be done in accordance with San, Joaquin County ! <br /> ordinances, state laws, and rules d gula ' s of Wan Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY_ © PER UNIT C1PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> FCHECKED <br /> ? <br /> BILLING REMITTANCE $ AMOUNT DUBASE EXPLANATION DATE DATE REMITTED - <br /> • � 7 <br /> FEE + <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> _ f <br /> OTHER <br /> Received by Rcept NoMailed Delivered <br /> Date t Dt <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />