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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 ereb mad to carry on business in the jurisdictional area of the an Joaquin Local Hea th District <br /> OF Business Name (DBA) Addresses• <br /> z Owner Address <br /> a .. <br /> J Firm Partners, Addresses and Teleph/one Numbers �7 <br /> aBusiness Telephone No. X66 ���l — Emergency Telephone No. _ . <br /> Contractor Licence No. zs — -�- <br /> L Applicants Name (Print) (L J• ,iz a 11Q -. Title 7 _ Date <br /> Please check Applicable Category (1-7) and Fill in the Required Into rmation O <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. 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 L cation Test Date/Time <br /> 4. SANITATION PET <br /> Jab Add ss/Location �l <br /> 0 ner Address ID12 PoNfewL6,6V /r te• <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD DOSEEPAGEPIT ❑ PACKAGE PLANT �. <br /> U PERMANENT ❑ TEMPORARY ANEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 Q t <br /> Type Construction Disposal Site s` <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 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and reg Iations of the <br /> ",San Joaquin Local Health District. <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 ❑ Jury 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 13 .-7 �21 <br /> Received by Date Receipt No Permit No. I suance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />