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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE F <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA1 Address } <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> EL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 1 <br /> L Applicants Name (Print} Title �' Date f i <br /> Please check Applicable Category (1-7) and Fill in the Required Information i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �I I <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 I <br /> 9 <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 ��11 } <br /> Job Address/L cation �/ 0� <br /> Owner Address 12.Sn 16 <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ EACHING FIELD 11 SEEPAGE PIT 11 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER ' <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 . <br /> Type Construction Disposal Site ` <br /> F 5 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> s <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 /> 3 <br /> © DRY CLEANING, Chemicals Used/Amount/Mo, j <br /> s <br /> 'I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and r gulations of the San J oaMum Local Health District.. <br />� 1 <br /> APPLICANT'S SIGNATURE X 1 <br /> LO <br /> -., FOR DEPARTMENT USE ONLY i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ i Aktt ❑.January 1 &Received By January 31 ❑ July 1 &Received By Jufy 31 tf <br /> BILLING REMITTANCE - $ �" :'AMOUNT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED -- �- '-AMOUNT I <br /> FEE 5- <br /> LESS LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> -OTHER - _ a <br /> pi 14 oma• ��.� <br /> Received 6y Date Receipt No. Permit No. J Issuance ate Mailed DVVered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 952 , <br />