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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 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ' ereb�made t a on b ss in the juris tional area of the Saf�oaquin Local Health District <br /> y Business Name (D Address— V 76 <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 16 Emergency Telephone No. <br /> Contractor Licence No. 3 j <br /> L Applicants Name (Print) Title Dale <br /> Please check Applicable Category(1-7)and Fill in the Required In maiion J <br /> 1.�❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> F 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. 4L <br /> Test L�tion Test Date/Time <br /> 4. &SANITATION PERMITS a <br /> Job Address/ ation _ <br /> Ow rAddress � - <br /> �EPTICeNK2' <br /> ❑ CESSPOOL ,., AGH G FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> M� PERMANENT ❑ TEMPORARY 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 /> Operator Name - - Where Certified <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 /> I hereby certify that I have prepared his application and that the work`Will be done in o ance with San Joaquin County <br /> ordinances, state laws, and rules' egulations of the 5 a n Local Health District. <br /> z, - .� <br /> APPLICANT'S SIGNATURE X <br /> P <br /> i FOR DEPARTMENTW E N Y + <br /> Y <br /> Fee Is Due: 11 ANNUALLY El PER UNIT El PER SITE El EACH ; anLary 1 6 Received By January 31 ❑ July+1 &Received By July 31 <br /> I BILLING EMI ANCE # $ REMIT <br /> BASE EXPLANATION PATE E REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE .F� '_A <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER <br /> Received by Date Receipt No. Permit No Llasuar4ce Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />