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Applications Will Be Processed When Submitted Properly 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 is hereby ma tto car on busin ss in the' ns ictional area of the San oa uin L al H Ith.Di trict <br /> Ca Business ame(DBA) Addres ��( " <br /> 4:w XW <br /> aOwner L Address <br /> 0 Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. `•. _ . . <br /> Applicants Name (Print) Title;. Ur 1�~ Date S5_rZ <br /> Please check Applicable Category (1-7) and Fill in the Required Information r �] <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) of <br /> For July 1, June 30,19 Disposal Sites. r' <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> f <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 w <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. ❑ SANITATION PERMIT <br /> Job Address/Location e f <br /> XOer °S Address <br /> EPTIC TANK C1 CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT- <br /> PERMANENT ❑ TEMPORARY NEW, . r ❑ 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) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified -- <br /> Plant Location <br /> Plant Capacity ice. 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 /> F f <br /> I hereby certify that-1 have prepared this application and that the work a don in accordance with San Joaqu ounty <br /> ordinances, state laws, an rule and regulations of the San Joaquin L al Health Dist 'ct. <br /> i k <br /> APPLICANT'S SIGNATURE X <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 /> _ REMIT <br /> $ <br /> BASE EXPLANATION BILLING REMITTANCE DATE DATE REMITTED AMOUNT DU HFCKED <br /> OyU�NyT <br /> FEE �, 1 l/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER _ <br /> OTHER <br /> S. Received by bate L pmcelipl-Nff. Permit No. issuance D ailed Delivered <br /> l <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTOI AVE.,P.O.Box 2009 STOCKTON,CA 95201 +� <br />