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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 /> r Application is eb ade to ry On usi ss in the jurisdictional area of the San Joaquin owl Health Di rict <br /> ,n Business N (DBA) Address <br /> zz Owner Address 510102� <br /> dK <br /> J Firm Partners, Addresses and Telephone Numbers• <br /> 0. Business Telephone No. G L V Emergency Telephone No <br /> -'Contractor Licence No. z <br /> Applicants Name (Print) G !` Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information CD <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. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. 9,SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ��IEPTIC TANK ❑ CESS OOL CW-4-EACHING FIELD fl-SEEPAGE PIT ❑ PACKAGE PLANT <br /> IQ'PERMANENT © TEMPORARY JR AWEW ❑ 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 pr this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an ules- r ulati e S Joaqu' Local Health District. <br /> 100, <br /> APPLICANT'S SIGNATURE <br /> of <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: D ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> PATE .DATE REMITTED <br /> AMOUNT <br /> FEEq��!000_ c <br /> LESS -{ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. ilssuandile Dat Mai d , Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE., . ox 2009., STOCKTON,CA 95201 <br /> � )1 <br />