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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE. £ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is rebs made to carry on business in th risdictional area of the San Joaquin Lo��He Ith Dist jct` <br /> rn Business Name BA) Address— r ¢� <br /> i Owner Address <br /> a <br /> 1 Firm Partners, Addresses an e ephone tubers <br /> i a Business Telephone No. Emergency Telephone No. <br /> a Z Z 2� <br /> Contractor Licence No. Date - <br /> L Applicants Name(Print) �— Title <br /> Q � <br /> l Please check Applicable Category (1-7) and Fill in the Req red Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,". June 30,'19 '� Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> 11 Serial No. <br /> CAL. License No. <br /> Capacity �* Gal.,Weights &Measures No. <br /> Equipment Parking Address t <br /> 2. ❑ PUMPER YARD << <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST <br /> � R.S.or R.C.E:-No. � <br /> R.S. or R.C.E. Name <br /> E <br /> Test L cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/ tion <br /> a 2� <br /> Ow r tr .Address <br /> IEPTIC TANK ❑ C SSP OL EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> i' LJ PERMANENT ❑ TEMPO <br /> s NEW ,r ❑ REPAIR <br /> C3 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1`7sJ6ne 3019 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) J <br /> o <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name t <br /> C� 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. T <br /> v <br /> I hereby certify that I have prepared this application and that the work will be doe in accordance with San Joaquin County <br /> ordinances, state laws, and rules ^regulations of San Joaquin Local Health District. # <br /> I APPLICANT'S SIGNATURE X <br /> 4 +'f <br /> FOR DEPARTMENT USE ONLY <br /> 4 <br /> Fee IS Due: ❑ ANNUALLY � �❑-PER UNIT- El PER 5171= ❑ EACH 11 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> . REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> �d <br /> FEE <br /> 1 � - <br /> LESS <br /> PRORATION <br /> PLUS <br /> f <br /> PENALTY ° - _ <br /> a, <br /> OTHER r <br /> i <br /> i <br /> OTHER - - - <br /> r � <br /> Receipt No. Permit ND. Issuance Date Mailed Deli ered <br /> Received by - Date - 1601 E.HAZELTON AVE,,P.O.Box 2009- STOCKTON,CA 95201 <br /> --- APPLICANT—RETURN ALL COPIES TOE' ENVIRONMENTAL HEALTH PERMITISERVICES - ... <br />