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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 /> Application is hereby made to carry on business in the jurisdictional area of the San.Joaquin Local Health District <br /> rBusiness ame (DBA) " ` ;• Address + �� <br /> z Owner Q, Address 41 f �"` r3 -.. ./ <br /> Q , <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. '2'� f r Emergency Telephone No. <br /> Contractor Licence No. = . <br /> a t ,�. t . 1 r �,4 t .�,: / <br /> L Applicants Name (Print) .� Title Dae <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 Juy 1, June 30, 19 <br /> No. dTVehicles 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. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑' EAHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 13 PERMANENT ❑ TEMPORARY UNEW ❑ REPAIR ❑ OTHER 4 - <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 s <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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws .and rules and regulations of the San.Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ —REMIT <br /> BASE EXPLANATION AMOUNT DUE `CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS _ <br /> PENALTY <br /> OTHER <br /> OTHER <br /> F <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 95201 <br />