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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 /> Appl ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ` <br /> OF Name (DBA) i- <br /> Address <br /> > <br /> a <br /> aOwner y ;Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. ' ! Emergency Telephone ND. s <br /> -L Contractor Licence <br /> LAppiicants Name(Print) -- Title <br /> Please check Applidatile Category (1-7)and Fill in the Required Information t '!'l <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) [ <br /> For July 1, June 30, 19 i Disposal Sites - <br /> Description(Make/Yr., Color) <br /> CAL.'Cicense Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 . "I <br /> No. of Vehicles Stored <br /> r <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST Y� , <br /> R.S. or R.G.E. Name ` ' x R.S. or.R.C.E. No. <br /> Test Location <br /> Test Date/Time <br /> 4 <br /> 4. ❑ SANITATION PERMIT�f t r� 3 f <br /> MA z kg�rffv <br /> Job Address/Location G� I <br /> O��,w,�n r 5 Address l <br /> LYSEPTiC-TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PER ❑ TEMPORARY I ❑ NEW ❑ REPAIR t ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30,'19 <br /> Disposal Site '° �- J <br /> Type Construction . <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where, <br /> _ Certified <br /> 1 <br /> Operator Name } <br /> Plant Location ° > <br /> s € <br /> "Plant Capacity No..Units Seryed <br /> 7. ❑ LAUNDRY For July 1, <br /> -June 30, 1.9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1',000 Sq. Ft. p i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. — i <br /> 14. <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 regylations of the San;Joaquin Local Health District. i <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT.USE 0NL"Y- July 1 &Received July 31 <br /> f <br /> 4 <br /> Fee Is Dike. ❑ ANNUALLY ,_ ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive;-By January 31 ❑ REMIT <br /> BASE i' EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED , <br /> _ f DATE -- - DATE REMITTED" AMOUNT <br /> FEE j <br /> LESS .N <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> t7THER <br /> OTHER <br /> i <br /> Received by Date Receipt No. Permil No�Lf., ' sua a Date Maled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTDN,CA 95201 <br />