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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable,.Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application I,s M adetoc9lonjUain sin the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address <br /> rn <br /> Z Owner Address' <br /> Address <br /> j Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No.,. zz�1 � G s 466 Emergency Telephone No. W <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date T <br /> Please check Applicable Category(1-7)and-Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I` <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, <br /> Equipment Parking Address <br /> 2. Cl PUMPER YARD <br /> For July 1, June 30, 19 .r <br /> r No. of Vehicles Stored - 1N <br /> C 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 /> F Test Location Test Date/Time + <br /> 4.`SANITATION PERMIT �� <br /> Job Address/Location t <br /> OwnerAddress <br /> 01-SEPTIC TANK 13CESSPOOL l s,[ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> gEZERMANENT ❑ TEMPORARY ANEW ❑ 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 /> i. 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator.Name " <br /> Where Certified <br /> Plant Location _ <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> R SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. >ow <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared this application and that the work will be done in accordance withan Joaquin County <br /> _ <br /> ordinances, state laws, and s and eguI ti S of the San Joaquin Local Health D' trict. <br /> APPLICANT'S SIGNATURE.X <br /> FOR DEPARTMENT-USE ONLY = <br /> Fee Is Due: 1:1 ANNUALLY ❑ PER UNIT C1 PER SITE ❑ FACH 13 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ' L/ c ! Is <br /> LESS Kc <br /> PROBATION <br /> PLUS <br /> PENALTY - <br /> OTHER - <br /> OTHER r <br /> < �s 1 <br /> Received by Da Receipt No. Permit No. IsIsuande Date Mailed Delivered <br /> t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> C t/, <br />