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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION a� <br /> _ (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> r Application is eby made carp business in the jurisdictional area of the r)o�uinoc4I Health District ! <br /> Hr Business Name (DBA) : Address <br /> i Owner Address <br /> J Firm Partners, Addresses and Telephone Num berss <br /> aBusiness Telephone No. C1106-5,e&67 Emergency Telephone No. <br /> Contractor Licence No. s <br /> q 1 <br /> Applicants Name (Print) �...[9 4 ' C' 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 <br /> Description(Make/Yr., Color) y <br /> Serial No. CAL. License No. CAL. Li"n&e Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> i <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.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Lo tion <br /> Owner Address QO <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ P CKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site i <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 /> Plant Location I( <br /> Plant Capacity No. Units Served J <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 thework will be done in accordance with San Joaquin County k <br /> ordinances, state laws, and rules and reg tions o San Joa in 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 i <br /> SICCING REMITTANCE REMIT <br /> $ <br /> BASF / EXPLANATION AMOUNT DUE CHECKED <br /> f DATE DATE REMITTED AMOUNT <br /> O <br /> FEE <br /> LESS 2 y o <br /> PRORATION <br /> PLUS fl <br /> PENALTY '�! ! <br /> OTHER <br /> OTHER <br /> I <br /> Received by Date Receipt No. Permit No I uanc Date 6failed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,. 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />