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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) <br /> 3� ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> .Application is by made o rry busi �s in the jurisdictional area of the San Joaquin Local at strlc <br /> cn Business Name O ) Address <br /> z Owner Addressr <br /> a <br /> M0 Firm Partners, Addresses and Telephdne Numbers <br /> 5. Business Telephone No. Emergency Telephone No. <br />�- Contractor Licence No. <br /> 1 Applicants Name (Print) Title Date <br /> I r Please check Applicable Category (1-7) and Fill in the Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />' ForPJuly 1, June 30, 19 Disposal Sites Cn <br /> Description(Make/Yr., Color) x <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD Y' <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored It <br /> 3• ❑ PERCOLATION TEST r"w <br /> -R.S. or R.C.E. Name R.S..or R.C.E. N.O. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT t 4 f <br /> Job Address/Location L74 (I <br /> Owner Address # ' <br /> SEPTIC ANK ❑ CESSPOOL LEACHING-FIEL-13—❑1SEEPAGE PIT 0 PACKAGE PLANT - <br /> PERMANENT' ❑ TEMPORARY NEWREPAIR ❑ OTHER d <br /> 5. ❑ CHEMICAL TOILETS For July 1, -Ane 30, 191 ,^ <br /> Type Construction Disposal Site V <br /> py%g <br /> No. of Units Equipment Storage/Cleaning Location(s) s <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, June 30,19 s <br /> Operator NameWhere"Certified' <br /> r <br /> Plant Location -- ---- --w- - ---F <br /> Plant Capacity � No. Units Served <br />! 7. ❑ LAUNDRY For July 1, -June 30, 19 T r <br /> SIZE: ❑ Less Than 1,000^Sq7Ft.r----11-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 <br /> j ordinances, state laws, and rules and&eut' s f the San aq 'n Local Health District. $ - <br /> APPLICANT'S SIGNATURE X s <br /> . .� _ <br /> FOR DEPARTMENT USE ONLY <br /> I <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE � - <br /> 6 <br /> l . <br /> LESS <br /> { PRORATION /y <br /> PLUS <br /> - PENALTY <br /> E {E OTHER <br /> iI •` _ <br /> + OTHER ....: _ s <br /> �. Received by- Date Receipt No Permit No. Is uance ate Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601.E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 - , <br />