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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 m-add to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name {DBA) 4r7. .✓ til-e t'+" ���+°�O �- Address -s <br /> z OwnerAddress --� -- <br /> a G <br /> Firm Partners, Addresses and Telephone Numbers <br /> KCL Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> L 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 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 n <br /> 2. ❑ PUMPER YARD V�+ <br /> For July 1, June 30, 19 <br /> No. of Vehicles 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. 1a1 <br /> Test Lo tion Test Date/Time <br /> 4. ErSANITATION PERMIT <br /> Job Address/Location Z 6 <br /> Owner Zl + Z"' 'W a Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT C1 PACKAGE PLANT / <br /> ❑ PERMANENT E] TEMPORARY ❑ NEW C1 REPAIR L1OTHER Cj,,�4v,,gC,i ,,r Al <br /> 5. E] 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 <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 Ak <br /> FOR DEPARTMENT USE <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH Ja ry 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLINGRVDE <br /> CE $ AMOUNT DUE CHECKED <br /> DATE //REMITTED AMOUNT <br /> FEE • pQ. dQ <br /> LESS t <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER 71 <br /> Received by Date Receipt No. eR Nv 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 />