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ApplicationsWill Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> its ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is reby made to rry an busi t �s�t nnal area of the Sa oaquin Local Health District <br /> Business Name DBA} Address 7 <br /> z Owner <br /> Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. S <br /> Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) . + Title ( ? <br /> Please check Applicable Cate o Date y z C! U r <br /> g ry (1-7}and Fill in the Required nformation � <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. <br /> Capacity GAL. Liccnse Renewal No. r, <br /> Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 i <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 Lnation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addres ot; ion .3550 <br /> Owner yca ei 6-s�� 1 <br /> Address d _CSP .cam •Oi <br /> ❑ SEPTIC TANK CESSPOOL ❑ LEACHING FIELD AGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW [REPAIR ❑ OTHER Q <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 . <br /> Type Construction Disposal Site <br /> of Units _ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -'June 3o,19 <br /> Operator Name Where Certified <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 /> 1 <br /> V <br /> I hereby certify that I have prepared this application and that the work will be do in c fiance with San Joaquin County <br /> ordinances, state laws, and ru nd regulations of San Joaquin.Local Health Di ¢t. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT U NL <br /> Fee is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ CH January 1 &Received By Januar 31 July 1 &Received f <br /> By July 31 <br /> BASE EXPLANATION BILLING MITTANCE $ REMIT <br /> DAT DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION _ <br /> PLUS l <br /> PENALTY <br /> OTHER J <br /> OTHER <br /> neceived by - - Date Receipt No. Permit o. � <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESIH c Date Mailed - Delivered <br /> 1661 E.HAZELTON AVE.,P.O.Bat 2009 STOCKTON,CA 95201 <br />