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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 9� �! .'or Non-Transferable, Revocable, and Suspendabie) SEPTAGC <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> aBusiness Name(DBA) - Address <br /> i Owner - Address/-99 <br /> 2 Firm Par ners,Addresses and Telephone Numbers'— f <br /> C6 Business!Telephone No. Emergency Telephone No. <br /> Contractlr Licence No. <br /> i �1�Lf >!?Ied' Date <br /> �ApplicanJ�ts !Name [Print) �� �- r Title <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 11, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. <br /> ICAL. License No. CAL. License Renewal No. <br /> Capacit Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of V hicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. W PERCOLATION TEST f <br /> R.S. or Fj.C.E. Name C- �C- R.S. or Redo. 1-1411 <br /> Test Loclation �� Test Date/Timeol <br /> 1 4, ❑ SANITATION PERMIT ° <br /> + Job Address/Location <br /> Owner I _ Address °Q <br /> + ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ElREPAIR ❑ OTHER <br /> 5. ❑ C'HEMICAL TOILETS For July 1,-June 30, 19 <br /> + Type C Instruction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) ro <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified 1 <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> FNS.eawrrercr€f;srisP.X13 ^i'�saf natsre Cti`i�ath�{o'Rtsir.cf;"Iner�rt ` `??ti?�-'`G"313nC•PCS#hPh'^rl<fr"iv4,:,cifhispermitic issued,lsha:1nmturnployarty perScirl +. <br /> II', {.'�Fr:ni,ge as t0 C;P rfm Stl-Ned fC N't kmYT i1 <br /> Ca tractcr'� hir:> hr soli-co�irErtin �Igr to+r� Lerit:sns tie Zvi+Jvy,r7: 'I cerlify th; t ,,t`?e pCr;Gri i i.: v C'€:?tt vii;k for uhiOlhi5 permif i-,iSSVE,.j Shall <br /> ertiploy Nefso;s SUbjeci i0 V.'Orrrrlan'5 CC;�NCriba,;Em laVis of <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, an rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X t' <br /> FOR DEPARTMENT USE ONLY <br /> Fie Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 $Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> CAMOUNT <br /> FEE <br /> LESS <br /> POORATION <br /> P US <br /> PENALTY <br /> OTHER <br /> O HEF R <br /> 17h, by Date Receipr o. ermit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />