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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheAppucauon <br /> APPLICATION <br /> -4 (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made carry on busipqss.in the' risdictional area of the *JoaLooc_a�I�Hpalth D' trictrn Business N DBA} Addres ,z Owner C AddressJ Firm Partners, Addresses nd Telep one Numbers <br /> CL <br /> Business Telephone No. �.5 �3� Emergency Telephone No. <br /> Contractor Licence No. d E7 <br /> L Applicants Name (Print) z Title'r Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) dJ <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 <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 PERMIT �p <br /> Job Addre s/Location Q 4�Cr e <br /> Ownerk. Address 41� <br /> C�EPTIC TANK 11 CESSPOOL �'CEACHING FIELD 9?SEEPAGE PIT ❑ PACKAGE PLANT <br /> dPERMANENT ❑ TEMPORARY 0-V EW ❑ 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 /> 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 e prep d this applic i n d at the work will be done in accordance with San Joaquin County <br /> ordinances, state la and r and r gulatio of e n Joaquin Local Health District. O <br /> 47 <br /> APPLICANT'S SIGNATUR <br /> ry <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Re ived B 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE RE D AMOUNT <br /> d <br /> FEE <br /> k �� c. <br /> LESS <br /> PRORATION / <br /> 1 <br /> PLUS <br /> PENALTY C <br /> OTHER <br /> OTHER <br /> Is u ince Date Mailed Delivered <br /> Received by Date Receipt No. Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />