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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION s <br /> °" (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> "j ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icatio reby made o carry on bu s in the j Ictional area of the San Joaquin Local Health District <br /> tiBusiness Name (DBA) ��� _ Address <br /> z Owner __ Address <br /> J Firm Partners, Addresses an 1 hon Nupbers <br /> aBusiness Telephone No. � Emergency Telephone No. h <br /> Contractor Licence No. _ �J <br /> Applicants Name (Pri �� Title Date <br /> y! <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ' <br /> For July 1, June 30, 19 Disposal Sites h <br /> G <br /> Description(Make/Yr., Color) _ <br /> Serial No. CAL. License No. License Renewal No.I <br /> i <br /> Capacity Gal., Weights & Measures No. E <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 s + } <br /> R.S.or R.C.E. Name R.S.or R.G.E. No. ! # <br /> Test Location lest Date/Time <br /> 4. ❑ SANITATION PER _ <br /> Job Add /Locati = jm <br /> Own — , d dress <br /> suI' <br /> ❑ TIC TANK ❑ CESSP06C \ ❑�-,�LEACHING FIELDi C-SE PAGE PIT ❑ PACKA PLANT � �- � ► \ Yv�� <br /> G�ERMANENT ❑ TEMPORARY I—NtW I❑ REPAIR r0 OTHER <br /> 5. ❑ CHEMICAL TOILETS For Judy 1, -June 30, 19 , tC7 <br /> Type Construction' I Disposal Site p� <br /> No. of Units Equipment Storage/Clesningi Location(s) <br /> 6. ❑ PACKAGE'TREATMENT PLANT For July 1, -June 3&n!q <br /> Where Certified + <br /> Operator Name ` <br /> Plant Location _ <br /> Plant CapacityN0. Units Served f - - <br /> 7. ❑ LAUNDRY For July 1, -June�0, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. FE ❑ More Than 1,000-Sq--Ft. i <br /> ❑ DRY CLEANfNG-Chemicals U es d/Amount/Mo. <br /> �_ �-rr-••��� � ���JiC��„ S�' ��" �.�•�_ ` a�Clp �=�J/v 7d ;�i,3PT r i _..�'' � <br /> - � {..rte—i •''�= �^s # „" � <br /> I hereby certify that I have pre red is applicatibnia he work will;tie-done in accor a"Mance witYr`5dr "Joaquin1- my I i <br /> ordinances, state laws, and ru a regulations an,Joa n Local Health-District. ; <br /> APPLICANT'S SIUN <br /> + �. <br /> c ¢ • 1 -- ' <br /> w OR DEPARTMENT UiE70NCY»1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE _ ❑ EACH ❑ January 1 Received By January 31 ❑ July 1 &ReceiveVBy July 31 <br /> t �'• REMIT ' <br /> BASE EXPLANATION BILLING REMITTANCE-A2 $ AMOUNY DUE ''c- CHECKED ' <br /> DATE DATE ,^ /- •REMITTED- s P` - AZMOUNT <br /> FEE <br /> LESS I <br /> PRORATION _ `•'" <br /> - i <br /> PLUS <br /> PENALTY �^ s a <br /> OTHER "`, --•. <br /> OTHER i <br /> 1 ° ''_ 3 311 <br /> Received by Date Receipt No. Permit No. 1 uan Date Mailed Delivered i <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMiTISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201.r' <br />