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Applications Will Be Processed When Submitted Properly Completed. Isesure 10 asgn I11+.�+r �a••� <br /> APPLICATION <br /> (For Non-Transferable,Revocable,"and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica n Is,�ier made to ca usl less in the jurisdictional area of th San Joaq in Local Heal District <br /> C"l L1 y�� 1 _Address y <br /> rn Business Name (DBA)■� �— <br /> aOwner Address <br /> Firm Partners, Addresses and Tejqphone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. i <br /> Date <br /> �Applicants Name (Print) <br /> 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.No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMITN <br /> Job Address/ tion <br /> Ow er Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 .-.Q <br /> Type Construction Disposal Site 6 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 /> � <br /> Y � <br /> hereb certify that I have prepared this application that the work will be done in accordant with n aQ i 0 <br /> ordinances, state laws, and rules and s o e 5 aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januar 1 &R 'ved By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE '/li REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 4-1 <br /> Received by Date Receipt No Permit No. Iss ante We ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />