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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION j <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 1 <br /> 'r <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District F <br /> 1yr <br /> OF Business Name (DBA) ASW Address. <br /> aOwner Address '1 <br /> Firm Partners, Addresses and Telephone Numbers 1 <br /> aBusiness Telephone No. �39 Emergency Telephone No. <br />` Contractor Licence No. <br /> Applicants Name (Print) 616Title ar't�NDate_7 7-8-21 <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., Color) <br /> CAL. License No. CRL. License Renewal No. <br /> Serial No. ! <br /> Capacity Gal.,Weights &Measures No, a <br /> Equipment Parking Address . <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 t <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 /> Test Location Test Date/Time <br /> 4. 9 SANITATION PERMIT b fps <br /> Job Address/Location 6 7-p <br /> � Owner <br /> pt Address <br /> t SEPTIC TANK ❑ CESSPOOL 0 LEACHING FIELD IN SEEPAGE PIT. ❑ PACKAGE PLANT <br /> C] OTHER <br /> PERMANENT ❑ TEMPORARY � NEW El REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> f Type Construction Disposal Site <br /> r 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 <br /> PNo. 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 /> i ordinances, state laws, and rules and regulations of the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> -74(P -- 02, <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑.EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE: $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS l <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ` Received by Date Receipt No. Permit. L issuance Date I Mailed Delivered <br /> 4 v <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH,PERMIT/SERVICES 1507.E.HAZELTON AVE.,P.O.60x 2009 STOCKTON,CA 95207 <br />