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Applications Will Be Processed When Submitted ProperlyCompleted. Be sure 1o sign InexpPAGa71V11- <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i eby made tU arry on bu ' ess in the�uri tionaI area of the S Joaquin Local Health District f <br /> .n Business Name (�&�JTdpn"hn' <br /> Addressz Owner ddressaFirm Partners, Addresses anene Numb�ers - <br /> CL <br /> Business Telephone No. ^ �� Emergency Telephone No. [�r� <br /> Contractor Licence No. = <br /> L Applicants Name (Print) Title Date I j <br /> Please check Applicable Category (1-7)and Fill in the Required Information ; <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) lJ� <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License No. s 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. Name R.S. or R.C.E. No. <br /> Test L tion Test Date/Time <br /> 4. SANITATION PERMIT (1.; <br /> Job Address/ atipn 15 <br /> Owner Address,� 11W <br /> 1111SEPTIC TANK CESSPOOL ❑ LEACHING FIELD l[�� SS PAGE PIT' PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW V PAIR ❑ 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 O <br /> Operator Name Where Certified <br /> Plant Location r <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 /> A <br /> 1 <br /> t <br /> 1 <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done acc ante with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health hist <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ON <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J ar &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITT $ AMOUNT DUE CHECKED <br /> DATE D REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER Za <br /> Received by Date Receipt No. Permit 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 96201 <br />