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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r APPLICATION <br /> ~` (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application iJ69A,,, td rc n uslne s in the jurisdictional area oft San J aquin Lo al ealth Distr'ct <br /> Business Name (DBA) Address -- <br /> aOwner Address <br /> Firm Partners, Addresses and Te h ne bers <br /> aBusiness Telephone No. � f Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Titled 1'1 !�. 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. 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 � C, <br /> R.S. or R.C.E. Name � R.S. or�R.C.E. No: <br /> Test ocation ` r _TPst Date/Time' <br /> 4, SANITATION PERM <br /> Job Addres /Loc tion _ <br /> Owner -� } — Address - <br /> ZKSEPTIC TANK b''CESSPOOL li LEACHING FIELD 'f SEEPAGE PIT ❑,PACKAGE PLANT <br /> -iZPERMANENT i O'TEMPORARY ❑ NEW IR REPAIR t ❑ OTHtR <br /> 5. ❑ CHEMICAL TOILETS For July 1, une 30, 19 C <br /> Type Co6itruc1ion'_->'' 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 I r Where Certified <br /> Plant Location o 4t, _ <br /> %Plant Capacity No. UnitsiServed <br /> .7:![:] LAUNDRY For July A�June 30, 19— <br /> SIZE: <br /> 9 SIZE: 1❑ Less Than 1,000 Sq. Ft., ❑,More Than 1,000 Sq. Ft "k 1 <br /> "DRY CLEANING, Chemicals Used/Amount/Mo. t <br /> I hereby certify that I have prepared this applicV174 and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules a n of e n Joa Liri Local Health District. <br /> 'APPLICANT'S SIGNATURE X <br /> k^ -- •-.- y.- -- FOR DEPARTMENT USE ONLY- <br /> Fee <br /> NLYFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ©•EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED �� AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS f <br /> PRORATION �/ "J- <br /> PLUS <br /> f <br /> PLUS /� <br /> PENALTY — - i�✓� �Gll4�i <br /> OTHER <br /> L <br /> OTHER <br /> i a <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95901 <br />