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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign Ineswppimauvrl. <br /> APPLICATION <br /> K (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i hereby made carry on business in th juri ctional area of the Sa oaquin Local Health District <br /> OF Business Name (D ) Adyess <br /> i Owner ddress <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> ILBusiness Telephone No. � O.S Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Title Date <br /> L Applicants Name(Print) ' <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 <br /> Description(Make/Yr., Calor) 1 <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> r <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 /> "a Test Date/Time J <br /> Test Lo ion <br /> 4. SANITATION PERMIT # a <br /> Ll <br /> Lj <br /> Job Address/Location <br /> Owner Address - <br /> ❑ SEsow <br /> PTIC TANK 13 CESSPOOL LEACHING FIELD SEEPAGE PIT 13 PACKAGE PLANT r� <br /> ❑ PERMANENT ❑.TEMPORARY ❑ NEW REPAIR ❑ OTHER �j 1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction t Disposal Site ; <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July.1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location y <br /> Plant Capacity No. Units Served �fl <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 40 <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 regulations oft an 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 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 00 <br /> FEE J S <br /> LESS s <br /> PRORATION <br /> PLUS rr <br /> PENALTY <br /> OTHER <br /> U <br /> OTHER <br /> Received by Date Receipt No- Permit No lssuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />