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Applications Will Be Processed When Submitted Property 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 ' heeby rpde to carryon bus neM in the jurisdictional area of the an J quin Local Health District <br /> HBusiness Name (DBA) r ddress <br /> r Address <br /> a Owner <br /> J Firm Partners, AddresseAand ephone N mbers <br /> aBusiness Telephone No '�9 b Emergency Teleph ne No. <br /> Contractor Licence No. <br /> DateApplicants Name (PrintTitle <br /> Please check Applicable Category (1-7)and Fill in the Required Information e <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. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time i <br /> 4. SANITATION PER IT <br /> Job Address/ cation G-.Arm_ <br /> Address <br /> Owner <br /> 4 ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD XSFEPAGE PITS ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ?(NEW X 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 p <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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, a rules and r ulationSan Joaquin Local Health District. <br /> s <br /> If <br /> APPLICANT'S SIGNATURE X <br /> Y <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 /> REMIBASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE J <br /> LESS <br /> PRORATION _ <br /> PLUSIr <br /> PENALTY � <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No ssua a Date MailedDe ivered <br /> . <br /> APPLICANTRETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKT N,CA 852 <br />