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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 2Ss r`70—07 <br /> Applicatio i hereby m de to carry business in the jurisdictional'area of the an Joa inl�ocal H alth Di tact - <br /> N Business N m (D A) Address <br /> E z Owner � . AddressV <br /> Firm Partners, Addresses and T lep o um s <br />€ a Business Telephone No. t _Emergency Telephone No. Uj <br /> r Contractor Licence No. <br /> i L Applicants Name (Print)---/ Title, Date 1 <br /> Please check Applicable ategory (1-7)and Fill in the Required Information <br /> l 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 /> i 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 - - <br /> -No. of Vehicles Stored <br /> E -No. of Chemical Toilets Stored <br /> 4I 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name R.S. or R.C.E. No. <br /> E Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT y' <br /> r Job Address/Location Tl f pl 4 �! rj �c� f keATT�'a� W <br /> f Owner�� i r �- ���/- �7 Address <br /> ❑ SEPTIC TANK []*CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ 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 /> t 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 <br /> I hereby certify that I have pre ared this application an he work will be done in accordance with San Joaquin County <br /> ordinances, state laws;9P4 r s and regulations of th an Joaq 'n Local Health District. <br /> APPLICANT'S SIGNATURE X , <br /> - FOR DEPARTMENT-USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PERJUNIT _ i rPE_R SITE ' ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &:Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> SASE EXPLANATION AMOUNT DUE CHECKED <br /> - DATE DATE *REMITTED AMOUNT - <br /> FEE , / s� <br /> LESS <br /> PRORATION' - r <br /> PLUS <br /> PENALTY _ <br /> .OTHER <br /> OTHER <br /> Received by jDate 6 Receipt No. Permit No. Issuance Date Mailed Delive d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 F,HAZELTON AVE.,P.O.Box 2009 STOC TON,CA 201 <br />