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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 r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereb made to ca o siness in the jurisdictional area of the Sqq Joaquin Local Health District <br /> r Business a (DBA) Ad ress 4 (/_ ;r ' <br /> a Owner �M: A r & /f• omy q <br /> j Firm Partners, Addresses and Telephone Numbers #' <br /> aBusiness Telephone No. �i �3 Emergency Telephone No. S <br /> Contractor Licence No. t' <br /> a Applicants Name (Print) tC Title �W�' Date <br /> b <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 I� Disposal Sites <br /> Description(Make/Yr., Color) �M <br /> Serial No. CAL. License No. CAL. License Renewal No. v <br /> Capacity i�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 I� <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Dation IM Test Date/ 'me <br /> 4. ?SANITATION PERMIT <br /> Job Address/Lpeatcu 10b <br /> D <br /> Owner �� r Address <br /> !'J SEPTI�TA ❑ CESSPOOL VLA I G FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY MIN EW ❑ REPAIR ❑ OTHER <br /> I �!. <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, i9 $y <br /> Type Construction iDisposal Site <br /> No. of Units I�. Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name IIL Where Certified <br /> Plant Location <br /> Plant Capacity �� No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 i <br /> i <br /> SIZE: 13 Less Than 1,000 Sq. Ft., 13 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I hereby certify that I have prep Is applica' that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r a regulations S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> iM <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY �❑ PER UNIT XPER SITE ❑ EACH - ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE- CHECKED <br /> BASE I EXPLANATION DATE DATE REMITTED AMOUNT <br /> I� <br /> FEE <br /> LESS <br /> PRORATION <br /> h PLUS I! <br /> I PENALTY _ r <br /> OTHER I� <br /> OTHER I� <br />� � a <br /> -Received by Date Receipt'Receipt No. Permit No <br /> Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201, <br />