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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 hqMy made to c rry business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) Address <br /> aOwner Address <br /> j Firm Partners,Addre ses and Telephone N tubers <br /> a Business Telephone No: Emergency Telephone No. <br /> a <br /> Contractor Licence No. . jo <br /> L Applicants Name (Print) Title Date 4 <br /> Please check Applicable Category-(1-7)and Fill in the Required Information - y <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) _ 6 <br /> 1 <br /> For July 1,-----=--June 30,19— =_ Disposal-Sites <br /> Description(Make/Yr.,Color) <br /> iCAL. License No.. CAL. License Renewal No. . <br /> r Serial No. ., , <br /> Capacity 3 .�. Gal., Weights &Measures No. <br /> Equipment Parking Address , <br /> 2. ❑ PUMPER YARD x <br /> For"July 1, June 30, 19 { <br /> No. of Vehicles Stored 1 <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 /> i 4. ❑ SANITATION PERMIT <br /> � a l <br /> s <br /> Job Address/Location <br /> Owner Add ss <br /> �SEPTIC TA ❑ CESS OOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARY EW 11 REPAIR C3 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July i, -Ju a 30, 19 <br /> Type Construction # Disposal Site <br /> ' <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name <br /> Where Certified s <br /> : <br /> Plant Location 1 <br /> Plant Capacity " No. Units Served <br /> 7. ❑ LAUNDRY Fogy July 1, -June 36, 19 _ " — - - t <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 rul d regulatio the Sari Joaquin [7061 Health District. <br /> t li <br /> APPLICANT'S SIGNATURE X r ' 'E ;r " <br /> _► - �� max ,�� f r <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 h BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - q DATE i DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION -" <br /> PLUS <br /> PENALTY <br /> OTHER <br /> s 4 L T <br /> OTHER ...0-. <br /> r. <br /> 16906 � S <br /> Received by - Date 'Receipt No Permit No - - is ante D Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1681 E.HAZELTO .0.Be.2009 STOCKTON,CA 95201 <br /> T <br />