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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 /> LL a ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> Application is e�ade-to ry o us ss in-the jurisdigt_ional-area of.the San Joaquin Local Health Distri0E <br /> Business Na �e DBA) d '�' A T Address ��� -S:::7_. <br /> o k <br /> i Owner Address <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. G f Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name {Print) d Title 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 = 1 <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 I <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30,19 : E <br /> No. of Vehicles Stored ' <br /> No. of Chemical Toilets Stored f <br /> 3. ❑ PERCOLATION TEST ° <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test.Location Test Date/Tirrie <br /> 4. ❑ SANITATION PERMIT �7 <br /> Job Address/Location �� / <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL JErLEACHING FIELD OSEEPAGE PIT ❑ PACKAGE PLANT <br /> ,PERMANENT ❑ TEMPORARY I ON€W WREPAIR ❑ OTHER v <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br />.� Type Construction - x. Disposal Site <br /> No. of Units _ Equipment Storage/Cleaning Location(s) - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name I Where Certified <br /> Plant Location9 Y` ` <br /> Plant Capacity. No. Units Served m <br /> 7. ❑ LAUNDRY For July.1, -June 30, 19 <br />,r SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.� <br /> r ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have pre are his app Id 9that th work will be done in accordance with San Joaquin County <br /> ordinances, state_laws, and rt 1 nd regul oris the,San Jo uin Local alth District. , <br />�Y :APPLICANT'S SIGNATURE X <br /> j 4 FOR DEPARTMENT USE ONLY <br /> t - Fee IS Due: ❑ ANNUALLY ❑ PER{UNIT. El PER SITE E ❑ EACH El January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> _ REMIT <br /> BILLING REMITTANCE $ <br /> BASE tEXPLANATION AMOUNT DUE CHECKED <br /> _ DATE DATE REMITTED AMOUNT <br /> i FEE <br /> LESS s ► y <br /> PRORATION <br /> wr PLUS File k <br /> PENALTY <br /> I OTHER <br /> i . <br /> OTHER <br /> Received by Date Receipt No. Permit No. I suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 8.HAZELTON AYE.,P.O.Box 2099 STOCKTON,CA 95201 . <br /> s <br />