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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TheAppllcauon. <br /> APPLICATION <br /> (For Non-Transierable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is he b mad to car on b ess in the jurisdictional areaof the San.Joaquin Local Health District <br /> Business Name�(�) � � Address <br /> z Owner Address <br /> d 4 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Lf Emergency Telephone No. t <br /> IL Business Telephone No: _ <br /> Contractor Licence No. �] <br /> Applicants Name (Print} z) Title Date.- <br /> Please check Applicable Category (1-7)and Fill 1n-the Required Information t' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) 1 <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. _ <br /> Capacity , al.,Wetghfs&MeasuresNo. �y <br /> Equipment Parking Address <br /> 2. 1:1 PUMP <br /> ER-YARD <br /> For July 1, June 30,,19 -- <br /> � I <br /> No. of Vehicles Stored s <br /> No. of Chemical Toilets Stored = w J <br /> •3. PERCOLATION TEST ' !; <br /> R.S.or R.C.E. NamR.S. or R.C.E. No. " ~ <br /> e .� `�• <br /> ! Test Date/Time <br /> Test iLocation _ <br /> 4. SANITATION PERM-,,' 41 <br /> Job Address/Location 1 <br /> Owner <br /> t Address t 1 <br /> ❑ SEPTIC TANK ❑ CESSPOOL` LEACHING FIELD SEEPAGE PIT <br /> ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY\ NEW REPAIR El OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1 E-June 30, 19 <br /> Type Construction. Disposal Site <br /> No'. of Units Equipment S45rage/Cleahing Location(s) <br /> 6 �13 PACKAGE TREATMENT PLANT i1F6-r6uly 1, - Line 30, 19 �^ <br /> Where Certified I I <br /> Operator Name # I ry <br /> Plant Location <br /> No. Units Served f j <br /> Klant Capacity ,'`r <br /> 7f ❑ LAUNDRY For July 1, -June 30)19 <br /> 1 r <br /> 'SIZE: ❑ Less Than 1,000 Sq. Ft., More Thar 1,000 Sq. Ft. cz�;`. i <br /> ❑ DRY CLEANING,Chemicals Used/A mb un(2Mo. r I <br /> j I�hereby certify that I have prepared this application and thw he workw1T-be-doo irf` kordance inrith San Joaquin Count ' <br /> �,. . �"ardini.ances, state laws, and rules egulations the San J quin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> � � <br /> t <br /> Fe` "1's�DUe: ❑ ANNUALLY _❑ PER UNIT ❑ PER SITE E3 EACH ❑ January 1 &Received By January 31 El July 1 8 Received By July 31 <br /> REMIT <br /> ' <br /> BASE E%PLANATION ~ BILL'ING REMITTANCE $ AMOUNT DUE <br /> CHECKED <br /> DATE -f `r.-rREMITTED AMOUNT <br /> r FEE <br /> LESS <br /> PRORATION <br /> r <br /> PLUS <br /> 1 PENALTY <br /> 1 OTHER <br /> OTHER <br /> Received by Date ' i Receipt No. Permit No. - Issuance Date Mailed Delivered <br /> ` APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMITJSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />