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Applications Will Be Processed When Submitted Properly Completed, Be SureTo SignTheApplication. <br /> 6 APPLMATMN <br /> � Q 0 ST (For Non-Transferable, Revocable,:and Suspendable) SEPTAGE <br /> E r ENVIRONMENTAL HEALTH PERMIT <br /> i0V LIQUID WASTE <br /> Application' �made&F, <br /> bu ess in the jurisdictional area of the San Joaquin Local Health D' trpt <br /> ,n Business Address <br /> aOwner L �' Address ' <br /> 9 Firm Partners, Addresses and Teele.hone Numbers <br /> aBusiness Telephone No. ��" Emergency Telephone No. <br /> Contractor Licence No. <br /> Date <br /> Applicants Name (Print) ^ _ Title _ <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 30, 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 /> ` I Test Date/Time <br /> Test Location <br /> 4.,PKS flITATION PERMIT f <br /> Job Address/Location ' <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ��CHINGIELD 11 SEEPAGE PIT 11 PACKAGE PLANT , <br /> r ERMANENT ❑ TEMPORARY 1 ❑ NEW PAIR "❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 UN <br /> Type Construction Disposal Site <br /> No. of Units I Equipment Storage/Cleaning Location(s) ` <br /> fi. ❑ PACKAGE TREATMENT:PLANT For July 1, -June 30, 19 <br /> Where Certified, <br /> Operator Name <br /> Plant Location k <br /> Plant Capacity No. LIARS Served <br /> 7. ❑ LAUNDRY For July 1, `June 30, 19 <br /> SIZE: ❑ Less Than 1,00_0 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> t <br /> (' ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 4 , <br /> I hereby certify that I have p ared is application d th t the work will be done in accor th San Joaquin County <br /> ordinances, state laws, an ules reg ns h a oaquin Lo I Health District. <br /> k <br /> i <br /> APPLICANT'S SIGNATURE X 1 <br /> e <br /> ' t FOR DEPARTMENT U 0 L <br /> Fee IS Due: El ANNUALLY _❑ PER UNIT ElPER SITE ❑ EACH s ❑ nua Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE I EXPLANATION ' BILLING REMITT !" 'si AMOUNT DUE CHECKED <br /> DATE - DAT -REMITTED AMOUNT <br /> FEE S CA y <br /> LESS _ <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 4. <br /> Received by Date Receipt No. Permit No. Issuance Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON A .Box 200 STOCKTON,CA 95201 <br />