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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 i her y ade to carry.on business i the juri i%tional area of the San Joaquin Local ea Drict �1 <br /> CAF Business Name (DBA Address <br /> a Owner <br /> — <br /> 9 A dress <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Emergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No. ` <br /> L Applicants Name (Print) Title Date <br /> :� — <br /> Please check Applicable Category (1-7) an Fill in the Require information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) A <br /> For July 1, June 30, 19 Disposal Sites i <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 <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 R.S. or R.C.E. No. <br /> Test Location I Test Date/Time <br /> 4. 11 SANITATION PERMIT <br /> Job Address/Location {1 <br /> I : <br /> Owner dress <br /> ❑ SEPTIC TA ❑ CESSPOOL ❑ LEACHING FIELD ' SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY L❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> -41 <br /> .. <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 3 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> F <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, d ruland regal ns of the San Joaquin Local Health District. j <br /> APPLICANT'S SIGNATURE X <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 1 [f <br /> PRORATION <br /> PLUS 10/1- <br /> PENALTY <br /> U'/PENALTY <br /> OTHER <br /> i <br /> l OTHER <br /> 5�L! <br /> Received by Date ,j Receipt No Permit No, Issuance ate Mailed Id <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMITJSERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOC TON;CA 201 <br />