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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Replication. <br /> APPLICATION <br /> (For Non-Transterable,Revocable,and Suspendable) SEPTAGE <br /> . ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i olereby mad to carry on sineional area of the Sa Joaqui Local Hgalth District _ <br /> NBusiness Name A) address <br /> zQ Owner <br /> Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 6 Emergency Telephone No. <br /> K <br /> Contractor Licence No. .7-2— 7l d <br /> Applicants Name (Print) Title 4 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 1, June 3"0,"l 9 Disposal Sites ; <br /> Description(Make/Yr., Colorj <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 /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ``A'�'�-• +r <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> i I <br /> Test cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/L cation �M ZZ <br /> Ow r Address <br /> VPERMANENT <br /> �PTIC YANK CESSPOOL L�FAGHING FIELD ❑ SEEPAGE PIT 1:1 PACKAGE PLANT 1 <br /> I ❑ TEMPORARY ! EW ❑ REPAIR ❑ OTHER - <br /> 5. 11 CHEMICAL TOILETS� For July 1, -June 34, 19'_ <br /> Type Construction I Disposal Site # <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t r <br /> Where Certified <br /> Operator Name <br /> Plant Location <br />` Plant Capacity r I _' I No. Units Served <br /> 7. ❑ LAUNDRY ForrJuly 1, -June 30, 19 )►'+f: f <br /> ' <br /> SIZE: ❑ Less Than-1,000 Sq-rt.,... <br /> ., . I- More.Than 1 00 <br /> ha0 Sq.'Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ' <br /> �f 1 <br /> I hereby certify that I have .prepared this application and that the work will be done in acc r anc e.,/with San Joaquin County <br /> ordinances, state laws, and rules an regulations of the J aquin Local Health District. i <br /> APPLICANT'S SIGNATURE X 3 <br /> i <br /> n <br /> V <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ Januallf1 & eceived By January 31 ❑ July 1 &Received <br /> BAREMITu1y 31 <br /> SE EXPLANATION BILLING REMIT NC $ AMOUNT DUE CHECKED <br /> DATE D E REMITTED AMOUNT <br /> FEE <br /> LESS V <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER I r <br /> Mailed Delivered <br /> Received by - Date Receipt No. Permit No. - Issuance Date <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />