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/ Applications Will Be Processed When Submitted Properly Completed, tie Sure To Sign i ne Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati�nn iis/h�ereb made to carr n bi4si ss in the jurisdictional area of the Sa �oaq n Local Health istrict <br /> Business a (DB, Addre s T <br /> Owner Address .�ls+(o�� A - •r 4 <br /> Firm Partners, Addresses and Telephone Numbers 1C<l Cf�FL�' '7yS'd6o� - <br /> Business Telephone No. .3 33 Emergency Telephone No. <br /> Contractor Licence No. 30SI2.41 <br /> Applicants Name (Print) te4 'S __ Title —64)ALt. Date <br /> Please check Applicable Category (1-7) and FIII in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,__,June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No-_ CAL. License No. CAL. License P,en Vwal No. <br /> Capacity _ Gal., Weights &Measures No. <br /> Equipment Parkirig.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. EErSANITATION PERMIT <br /> Job Address/Location 3 r70 /Vo' <br /> Owner Address <br /> ff SEPTIC TANK ❑ CESSPOOL BLEACHING FIELD [!SEEPAGE PIT ❑ PACKAGE PLANT <br /> Q-PERMANENT ❑ TEMPORARY a-NEW ❑ 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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified Chi <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 0, <br /> I hereby certify that I have pared is application and that the work will be done in accordant ith San Joaquin County <br /> ordinances, state laws,awj4les and la ons of the San Joaquin Local Health District. V <br /> 'J <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONL <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT 11PER SITE EI EACH Janu r Rec ived By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMI T $ AMOUNT DUE CHECKED <br /> DATE 0 T REMITTED AMOUNT <br /> FEE . % <br /> LESS <br /> PRORATION <br /> PLUS " <br /> PENALTY —- <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. isdulinco Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTON AVE_,P.O.Box.2009STOCKTON,CA 95201 <br />