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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The'Application. <br /> APPLICATION .. 1/ ' <br /> u, (For Non-Transferable, Revocable, and Suspendable) SEPTAGE i <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE i <br /> Appl icati er y carry on business i jurisdictional area of the San Joa in Local ct i <br /> FBusiness D ) Address <br /> aOwne t Address <br /> Firm Partners, Addresses and Tel hone Numbers <br /> CL Business Telephone No, Emergency Telephone No. 1 <br /> Contractor Licence No. ' <br /> Applicants Name (Print) 4 Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information lX� <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. <br /> Capacity Gal., Weights & Measures No. . _ I <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD t <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST j <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 <br /> Job Address/Location <br /> x O'c7�J <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT tt__ <br /> ❑ PERMANENT 13 TEMPORARY E] NEW 11 REPAIR OTHER VQ",' 1$\%00 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 6 <br /> Where Gertified <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 pr a this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules r ulations he San Joaquin Local Health District. <br /> � <br /> APPLICANT'S SIGNATURE X t <br /> J I <br /> FOR DEPARTMENT USE ONLY t}t <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 /> i DATE DATE REMITTFO AMOUNT <br /> FEE j I <br /> LESS <br /> PRORATION <br /> PLUS /J <br /> PENALTY !�"t�} <br /> OTHER '., 1%--o <br /> OTHER 1 <br /> /� 1 0 c> <br /> Received by I Dalh Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE:;P.O.Box 2009 STOCKTON,CA 95201 - - <br /> d <br />