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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) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> d <br /> LIQUID WASTE ' <br /> Application is rebytmade to garry on business in Pe jurisdictional area of the San Jo q in Local Health District, r �r <br /> yBusiness Name ` Address <br /> z Owner-=- Address � <br /> a .. <br /> J Firm Partners, Addresses and Telephone Numbed <br /> o. Business Telephone No. d Emergency Telephone No. <br /> Contractor Licence No. 2 <br /> Applicants Name (Print) <br /> t Title Date <br /> r <br /> Please check Applicable Category(�Ilnd�h.Require Information -- 4 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, Y June 30, 19 Disposal Sites t <br /> Description(Make/Yr., Color) <br /> Serial NO. CAL. License No. CAL. License Renewal No. <br /> Y <br /> Cap acit Gal.,Weights &Measures No. <br /> _ � <br /> Equipment Parking Address- I <br /> 2. 13 PUMPER YARD IF <br /> For July 1, June 30, 19 1 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored (may <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R. .E. Name R.S. or R.C.E.No. <br /> V'f <br /> Test L ation Test Date/Time k �` <br /> 4. EJ SANITATION PERMIT <br /> Job Address/Loc ti <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ ESSPOOL ❑ LEACHI G FIELD ❑ SS PAGE PIT 1:1 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW L7 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site f <br /> i <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> r Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served' <br /> .....+ ( 4 <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. r... .^ <br /> y <br /> I hereby certify that 1 have prepared this application and that the work Will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rulesregulations f the Jo uin Local Health District, t r <br /> ! t <br /> APPLICANT'S SIGNATURE X r x <br /> FOR DEPARTMENT USE ONLY i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT I <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ' DATE DATE REMITTED AMOUNT <br /> f <br /> 1' <br /> FEE - <br /> ./ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rec Date Receipt No ero. Issuance Date Mail V Delivered <br /> r` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box- — -STOCKTON,CA 95201 <br />