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x Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. . <br /> APPLICATION <br /> (Far Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> x ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ApQI Ica io her by mad car n busin s in the jurisdictional area of the San Joaquin Loc Ne lth str' k <br /> j y Business N e (DB ) Address <br /> - <br /> z Owner Address S - <br /> I D Firm Partners, Addresses and Telepho Numb rs <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> a l <br /> ` Contractor Licence No. <br /> I( Applicants Name (Print) Title Da1e <br /> s Please check Applicable Category (1-T) and Fill in the Required Informson <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, " June 30, 19 Disposal Sites <br /> F Description(Make/Yr., Color) <br /> Serial NoCAL. License Renewal No. <br /> . CAL. License No. <br /> �... ry <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 - <br /> No. <br /> 9 No. of Vehicles Stored <br /> I 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. XSANITATION PERMIT <br /> l ( <br /> Job Addre Location <br /> 6 Owner # Address <br /> SEPTIC TANK ❑ CESS OOL LEACHING FIELD C1 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> t' 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 I Where Certified <br /> - Plant Location <br /> Plant Capacity No. Units Served t� <br /> .7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. t �~ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> 1 , <br /> I hereby certify that I hav epared this application nd th t the work will be done in accordance with San Joaquin County <br /> ordinances, state law s and regulations the San o uin Local Health District. <br /> 6 APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER.UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> _ <br /> REMIT <br /> BILLING REMITTANCE $ <br /> i AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DATE REMITTED (( AMOUNT <br /> FEE <br /> LESS- <br /> PRORATION - <br /> PWS <br /> ,.PENALTY <br /> OTHER <br /> OTHER <br /> OTHER <br /> if <br /> n .. ._ 06 r7' '� V <br /> Received by - '-�� - Date Receipt No. Permit No. Iss ante Date Mailed - .Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICES 1601 E.HA'ZELTON AVE.,P.O.B,oxx 2009 STOCKTON,CA 95201 <br />