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Applications Will Be Processed When Submitted Properly <br /> APPLICATION <br /> (For Non-Transferable,•Revocable,{and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ' by ma rry on business in the jurisdictio_nal area of the San oaquin cal Health District. t <br /> I <br /> Address <br /> ,n Business Name (DBA) <br /> i <br /> Address <br /> Owner <br /> 4 <br /> u,Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone'No. 5 <br /> Contractor Licence No. Date CJ <br /> Title <br /> L Applicants Name (Print) _ <br /> Please check Applicable Category (1-7)and Fill in the Required Information ; ,qv ` <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> _.$)For July 11 June 30,19'' - <br /> - _ - - Disposal Sites � - <br /> Description(Make/Yr.,Color) CAL License No. I CAL. License Renewal No. <br /> Serial No. <br /> Gal., Weights,&Measures No. t <br /> Capacity # + + <br /> Equipment Parking k Address : Y 2. [1PUMPER YARDg z t �' y <br /> �} r <br /> For July 1, June-30;"19 �t <br /> 'No.of Vehicles Stored' <br /> No. of Chemical Toilets Stored 'm <br /> 3. ❑ PERCOLATION TEST R.S.-or R.C.E.No. - <br /> R.S. or R.C.E. Name Test Date/Time` <br /> Test L cation , <br /> 4. SANITATION PERMIT , <br /> Jo Address/ cation ti e— <br /> Addre s 0 PACKAGE PLAINT <br /> Owner <br /> TANK CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ OTHER <br /> ❑ TEMPORARY <br /> NEW 13 REPAIR <br /> PERMANENT <br /> 1 5• <br /> &SEPTIC <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Disposal Site <br /> I Type Constructionpd <br /> Equipment Storage/Cleaning`Location(s) <br /> Na of Units J <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 3019 I Where Certified <br /> r <br /> Operator Name I <br /> Plant Locationr <br /> n" No. Units Served <br /> r Plant Capacity - -- L <br /> r <br /> 7. 11 LAUNDRY For,July 1, -June 30, 19 =" <br /> 51ZE: 1:1Less Than 1,000 Sq'. Ft.,' ❑ More Than 1,400 Sq, Ft. _ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> _ � <br /> I hereby certify that I have <br /> red this application and that�the work will'be done in accordance with San Joaquin County <br /> ordinances, state laws, an es end g <br /> ulat' soft n Joa In Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Al <br /> ` FOR DEPARTMENT USE ONLYw.» + .• <br /> f` <br /> PERUNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31. ❑ July 1 &Received 8y July 31 <br /> Fee Is Dile: ❑ ANNUALLY ❑ - REMIT <br /> ON <br /> ECKED <br /> RETt'FANCE : $ AMOUNT DUE CH <br /> 61LLlNG � � AMOiJNT <br /> . <br /> BASE EXPLANATI :`l. DATE - TE <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLUS - ---^>! - 4 >€ , <br /> PENALTY - <br /> .OTHER <br /> OTHER - - y.. <br /> �3 �`fi ✓ 8 <br /> ,r' "- t '•` - - �' issua ce Date Mailed Delivered <br /> Date Receipt No. Permit No. <br /> Received'by - '1601 E.HAZELTON AVE.,P.O.Box 2009- STOGKTON,CA 45201 <br /> APPLICANTT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES i <br />