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t Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I APPLICATION I <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio erqy_made ca b ess i he' ri ctional area of the S Joa n Local Health District <br /> N Business Name (D ) Address 9 266 -7-7� i y <br /> aOwnerAddress <br /> Firm Partners, Addresses and Telephone Numbers i <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. �— <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required qhformation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O> <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 /> i <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 /> TesttLtion Test Date/Time <br /> 4. SANITATION PERMIT `'- <br /> Job Addres Location <br /> 0511<" Address <br /> Iff-SEPTIC TANK IJ CESSPOOL LEACHING FIELD ❑ ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR 0 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) l <br /> 6. ❑ PACKAGE TREATMENT PLANT For iJuly 1, -June 30, 19 <br /> Operator Name I Where Certified } <br /> Plant Location <br /> Plant Capacity No. Units Served I <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 /> � s <br /> I hereby certify that I have preparfd this application and that the work will be done in a c rdan e t S Joaquin C my <br /> ordinances, state laws, and rules and r lations of the San J Lin ocal Health Distric . <br /> ,l 1 <br /> APPLICANT'S SIGNATURE X r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE "❑ EACH ❑ January-1 & ecel d By January 31 ❑ July-l-&Received By July 31 <br /> REMIT ' <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> 5 DATE DATE REMIT ED AMOUNT <br /> D� <br /> FEE <br /> LESS .� I <br /> PRORATION I i <br /> PLUS <br /> PENALTY I <br /> OTHER k� <br /> OTHER <br /> Received by' Date Receipt No. Permit No. IsEfuance O to Mailed elivered 1 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O.Box 2009. STOCKTON,CA 95201 - <br />