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Applications Will Be Processed When Submitted ProperlyCompietea. 17ure 1Ua110E1 • ^rr <br /> AP KATION + <br /> (For Non-Transte le, Revocable,and Suspendable) SEPTAGE f <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is her y e to carry on 'ness� t jurisdictional area of the n J a Local alth trict >~ <br /> < <br /> y Business e (DBA) Address h <br /> Owner Address <br /> i <br /> I .�� <br /> 0 Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> 0. Business Telephone No. ��"P' S -3 <br /> Contractor Licence No. ds! RJt19r Date �'j� <br /> Title <br /> Applicants Name (Print} <br /> Please check Applicable Category (1-7)and Fill in the Required information f <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, <br /> June 30, 19 Disposal Sites <br /> -Installation"wll�serve: Residence (� Apartment House ❑ Commercial ❑ Trailer Court�� <br /> Motel ❑ Other -------------------- -- - <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 R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. P-SANITATION PERMIT r <br /> Job Ad�*� <br /> n <br /> Owner Address `� <br /> ❑ SEPTIC TANK CESSPOOLEACHING FIELD 91-SEEPAGE PIT ❑ PACKAGE PLANT 06 <br /> ❑ PERMANENT ❑ TEMPORARY 1:1 NEW <br /> Z1-REPAiR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 [� <br /> TypConstruction Disposal Site ; <br /> NS�l Units Equipment Storage/Cleaning Location(s) 1` <br /> /11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> Than 1,000 5q. Ft. <br /> SIZE: 11 Less Than 1,000 Sq. Ft., 11 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a lMan <br /> s and reg on of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> ❑ ❑ PER UNIT ❑ PER SITE 13 EACH ❑ January 1 &Received By January 31 ❑ July t &Received EMITBy uly 31 <br /> Fee IS Due: ANNUALLY <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED ` <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE ` S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY + <br /> i <br /> OTHER <br /> OTHER <br /> �e,-,eived by Date <br /> - 1 uance ate Mailed Delivered <br /> Receipt No. Permit No <br /> TO: ENVIRONMENTAL HEALTH PERMITlSERYICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES <br />