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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 ' hereby m toC rry on busi ss in the jurisdictional area of the S§;0 qu' Local Health District <br /> Business Name inPA) a+ Address <br /> aOwner +z Address <br /> J Firm Partners, Addresses and Telep//hhone Numbers <br /> aBusiness Telephone No. - gin, l Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) 7, Title Date 1 <br /> Please check Applicable Categ ry (1-7) and Fill in th equired 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. 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 77; <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. C 'SANITATION PERMIT <br /> Job/Addrr ation G" <br /> Owy>eF � A dress <br /> SEP ANK ❑ CESSPOOL fZC59CHING FIELD 93—SEEPAGE PIT ❑ PACKAGE PLANT <br /> 10+156MANENT ❑ TEMPORARY Q„Wf l' ❑ 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 q <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. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 3 <br /> hereby certify that I have prepay is application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule d regu tions olt0e San Joaquin ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> 01 <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 /> BILLING REMITTANCE - $ <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE I_//r 4 J <br /> LESS y� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT!$ERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />