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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - APPLICATION <br /> (For Non-Transierable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> r Applicatio ��by m e t ry usin the jurisdictional area of the S qui 11aYh Dis <br /> y Business Y(DBA} Address y" <br /> a Owner t Ad ess <br /> fl fr <br /> Firm Partners, Addresses and elephone Numbers <br /> a Emergency Telephone No. � <br /> a Business Telephone No. <br /> Contractor Licence No. _ ? <br /> LL _ Title Date f S <br /> Applicants Name (Print) f� <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 11 <br /> k1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> t <br /> I Description(Make/Yr., Color) � <br /> Serial No. CAL. License No. CAL. License Renewal No. 4p <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 A <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test�Location <br /> Test Date/Time <br /> 4. II�'SANITATION PERMI <br /> 1 �,2 <br /> Job Addres option Zlit - T �- <br /> Owner Address . <br /> ❑ SEPTIC TANK ❑ CESSPOOL 9?LEACHING FIELD O�..,, SS�EEPAGE PIT 11 PACKAGE PLANT <br /> 1 <br /> 11 PERMANENT 1:1 TEMPORARY ❑ NEW 9 REPAIR C3 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) p o <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 W <br /> Where Certified <br /> Operator Name <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. / <br /> I hereby certify that I have pLppa7 this applic ' n and t t the work will be done in accord ce with San Joaquin County <br /> j ordinances, state laws, an ule nd regulatio Joaquin Local Health D' trict. <br /> APPLICANT'S SIGNATURE X 4 <br /> i <br /> FOR DEPARTMENT U Ed <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH Ja ary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> L - REMIT <br /> ril BASE EXPLANATION BILLING E ANCE $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> FEE . <br /> LESS <br /> i rp,.-•�J PRORATION - <br /> PLUS <br /> PENALTY <br /> t OTHER <br /> OTHER - ` 10 <br /> pt No. Perms o. issuance Date Mailetl Delivered <br /> Received by Date Re <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKT N,CA 95201 <br />