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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 /> Applicati is hereby0ade to car n b si ss in the jurisdictional area of the S Joa��Local Health trict <br /> Business N e (DBA) Add ss WO jE <br /> z Owner r Address 00fM <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. 36 F70y3A Emergency Telephone No. <br /> Contractor Licence No. 4V57 21 <br /> Applicants Name (Print) <c Title QLt7 �� Date <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 /> 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.G.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT G �3 - /cam " a <br /> Job Address/ cation <br /> Owr O Address -5A -- <br /> L� SEPTIC TANK ❑ CESSPOOL &TEACHING FIELD S'SEEPAGE PIT ❑ PACKAGE PLANT <br /> Is PERMANENT ❑ TEMPORARY ❑ NEW 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 /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 W <br /> Operator Name Where Certified <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 /> I hereby certify that I have prepared this application And that the work will be done in accordance with San Joaquin County i <br /> ordinances, state laws, and rules a ulations of oaquin Local Health District. <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOU5NT <br /> FEE LIS <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 22 n <br /> Received by Date Receipt No. Permit No. Is uan , D to Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Boz 2009 STOCKTON,FzA 95201 <br /> reed �� + i q <br />