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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign IneApplication. <br /> APPLICATION <br /> r (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of th,e a quin Local Health District <br /> v;Business Name (DBA) �N�Address <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> E Business Telephone No. _ Emergency Telepho�No <br /> Contractor Licence No. _ r <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. GAL. Lic4nse 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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERIPITI <br /> Job Address/Location <br /> Owner aI Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT ' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> S. ❑ 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 /> t 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 certifythat ave prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, stat laws, rules and regulation' <br /> nt2!111 ulatioSan J aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r�r FOR PAR SE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT tel PER SITE ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> TE E REMITTED (/ AMOUNT <br /> FEE r <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O -30P--7 !1 / h <br /> Received by Date Receipt No. Permit No, Is uance Date Mailed !Deliv edAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601E.HAZELTONAVE.,P.O.Box20D9. O TON, <br />