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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 I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio �erymadjo ar n iness in the jurisdictional area of the San Joaquin L l Health D' ict <br /> HBusiness Name {DBA) Address l <br /> .Address <br /> za Owner— �. v <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No.; <br /> �,- – Emergency Telephone No. <br /> a <br /> � <br /> Contractor Licence No. <br /> Applicants Name(Print) Titled-%' Date <br /> Please check Applicable Category (1-7) and Fill in the Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 36,.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. ❑ 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 Location Test Date/Time <br /> 4. fid SANITATiON PERMIT <br /> Job Address cation <br /> Owner T Address <br /> 11 SEPTIC TAK ❑ CITSSPOOL ❑ LEACHING FIELD SEEPAGE PIT 13 PA AGE PLANT <br /> 1:1 PERMANENT C1 TEMPORARY 11 , <br /> NEW REPAIR 11 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 TAW <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ' <br /> Where Certified <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 /> r ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i I hereby certify that I•have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and and re ulation of the San Joaquin Local Health District. <br /> APPLICANT'S i SIGNATURE x <br /> - <br /> FOR DEPARTMENT USE ONLY <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 /> PATE - -DATE REMITTED .AMOUNT <br /> r FEE >� <br /> LESS <br /> PRORATION <br /> PLUS 4 <br /> PENALTY <br /> OTHER - <br /> t <br /> OTHER ... wq„ - . .. - ... ...w- .. - <br /> ��-z�{�-�z <br /> Receivetl by Date Receipt No. Permit No. 9suan ate Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.80■2009 STOCt(TON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICE5` <br />