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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> v,- (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application 's hereby made to carry on business in the jurisdictional area of the Sa Joaquin Local Health District _ <br /> yBusiness Name (DBA) �rC�°� Address <br /> z Owner i Address <br /> 4 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No.- <br />_J _ <br /> LApplicants Name (Print) Title ��"`� �%�`�` Date <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. Licen eNo. CAL. License Renewal No. # <br /> Capacity Gal., Weights & Measures No. <br /> t <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 1;55 <br /> For July 1, June 30, 19 - <br /> No. <br /> 9 No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION,-TEST '+ ;u w, y �. <br /> R.S. or R.G.E. Name fir+ R S.`or R.C_E."No. <br /> z= r <br /> Test location "` jest-Ddte/Time <br /> u <br /> 4. ❑ SANITATION_PERMIT4 <br /> Job Address/Locatiol��"�Tf <br /> Owner. � � �"�`" �_`��_ `; Address <br /> ❑ SEPTIC TANK ❑.-CESSPOOL_ 1:1-LEACHING FIELD 13 SEEPAGE PIT w ❑ PACKAGE PLANT <br /> *` t,'��' ❑ REPAIR ❑ OTHER <br /> ❑ PERMANENT -❑"TEMPORARY �❑ NEW <br /> 5. ❑ CHEMICAL TOILETS'For July-I Jurfe 30, 19 <br /> Type Construction ; Disposal Site <br /> No, of Units ' "-=� YEquiprhent Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-.June 30,,19 <br /> Operator Name "" Y-� �Wh4e 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 <br /> iM <br /> i <br /> K , <br /> I hereby certify that I have prepared this app cation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and r gula'tio s-of the an Joaquin Local Health District. <br /> f f - i <br /> APPLICANT'S SIGNATURE X <br /> s <br /> x ( J OR DEPARTMENT USE ONLY # <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER,SIT.E ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juty 31 <br /> F REMIT <br /> BASE- EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED " <br /> ¢f DATE DATE REMITTED i AMOUNT <br /> FEE # 71 .L � (}} <br /> LE55 (Via r 7 G C # <br /> PRORATION <br /> PLUS 1 <br /> PENALTY <br /> OTHER f <br /> Now L( <br /> Received by Date F iii Receipt NQS :Petmil No. I uance ate Mailed Delivered f <br /> APPLICANT—RETURN ALL COPIES TOi' ENVIRONMENTAL'HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9$201 1 <br />