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Applications Will Be Processed When Submitted Properly Completed. tae sure 10 alga.,-Ir> ��•� <br /> APPLICATION <br /> r. a (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati is hereby a to c^aTr_ry on business in the jurisdictional area of the San Joaquin Local Health District -� <br /> Business Name (DBA) D � ! Address-- .�' <br /> z Owner <br /> SLC Address d T <br /> C <br /> j Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. G Emergency Telephone No, <br /> Contractor Licence No. t <br /> Applicants Name (Print):` _ Title 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 1v June 30,39 Disposal Sites <br /> Description(Make/Yr., Color) p <br /> CAL. License Renewal No. <br /> Serial No. CAL. License No. +V <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD Wi. <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored � w <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E.`No. <br /> Test Location i Test.Date/Time' # i Ah-1 I <br /> 4. �TR�SANITATION PERMIT <br /> Job Addre L cation <br /> Owner <br /> Addressgo <br /> 3 <br /> VSEPTIC TANK:- 1:1CESSPOOLI ~WLEACHING-FIELDZ❑'SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY PCNEW�— ❑ REPAIR OTHER S'.4ep <br /> 5. ❑ CHEMICAL TOILETS For Jul , -June 30, 19 x <br /> ' <br /> Type Construction Disposal Site <br /> No. of Units__""f Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> I <br /> Plant Location <br /> Plant Capacity No,Units•Served <br /> LAUNDRII 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/Moll <br /> w 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 rulMFFDregulalions of th Sa, Joaq Local Health District. <br /> le <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 &ReceivedBy July 31 <br /> REMI' BASE EXPLAIN TION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. <br /> Issuance Date Mailed Delivered <br /> APPLICANT-:-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �. 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />