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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 O <br /> A,gplicati is hereb made toi .carry n b siness in the' risdictio al aiyj the Sa Joaq in ocal Hjealth District <br /> ,„Business Name (DBA) s <br /> dOwner rte~ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <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 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccase Renewal No. (� <br /> Capacity Gal.,Weights &Measures No. N <br /> Equipment Parking Address N <br /> 2. ❑ PUMPER YARD 1 i <br /> For July 1, June 30, 19 <br /> D <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT ;( <br /> Job Address/Loc tion 3Z"L <br /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL i�LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY gLNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 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 <br /> Operator Name i Where Certified <br /> Plant Location <br /> Plant Capacity I No. Units Served y <br /> 7. ❑ LAUNDRY -'For July 1, -June 30, 19' F <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 1 <br /> ordinances, state laws, and rules and regulations of San J qui cal Health District. <br /> APPLICANT'S SIGNATURE X <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �/ $ <br /> LESS <br /> PRORATION t <br />' PLUS <br /> PENALTY ' <br /> OTHER ,. <br /> OTHER <br /> D ,6.5,0 <br /> Received by Dale Receipt No. Permit No. Issu ce 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 /> r - i <br /> r <br />