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Applications Will Be Processed When Submitted"Properly Completed. Be Sure To Sign The Application_.. <br /> APPLICATION w <br /> 1 1 (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaqui n Local Health District <br /> Or Business Name (DSA) c 4 F0- C 4:=r_ Address r /�yr %CAS <br /> aOwner t�Cs Address <br /> J Firm Partners, Addresses and Telephone Numbers _ <br /> aBusiness Telephone No. e+'r '� Emergency Telephone No. <br /> Contractor Licence No. js <br /> i <br /> L Applicants Name(Print)—.. /� .�. � � ,•' Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 '1 <br /> For July 1, June 30, 19 Disposal Sites iJ <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 k <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/Location <br /> Address <br /> Owr� J� _ �Q�� <br /> ❑SEPTIC TANK �CICES�SPOOL LEACHING FIELD ❑ SEEPAGE PIT C1 PACKAGE PLANT <br /> ❑ PERMANENT , ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHERJ 7 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June-30,,19: <br /> Type Construction Disposal SiteR ' <br /> No. of Units y. `.' _E_quipment Storage/Cleaning Locations) ' <br /> 6. 1-1PACKAGET EATMENT PLANT—,For July 1;`June 30, 1T!" _ <br /> Operator Name _ <br /> € '- Where Certified <br /> Plant Location ✓ ." f _ - -- --�{ <br /> Plant Capacity F No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 11,000 Sq. Ft.. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that l knave prepared this-application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws;'and rules andre ti"— treSan oaquin Local Health District. j <br /> r <br /> APPLICANT'S SIGNATURE X <br /> f <br /> v 4r <br /> 41 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 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> t� AMOUNT <br /> FEE <br /> LESS y <br /> PRORATION - <br /> PENALTY <br />�--. '-"^OTHER�-. • -�-- -*p'- -- —.-. ,. ,_ -., _ ��" V�� 4� _ ' <br /> OTHER <br /> F-.- <br /> Received by Date Receipt No Permit No. Issu nce Datcl Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 - <br />