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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _ APPLICATION <br /> i' (For Non-Transferable, Revocable, and Suspendable) ? <br /> ENVIRONMENTAL HEALTH PERMIT / SEPTAGE I <br /> - LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District 9 <br /> rn Business Nam DBA) e rj� ddress S S <br /> a Owner�� Address� ._��� <br /> �,. <br /> Firm Partners, Addresses and Telep one Numbers — I <br /> CL <br /> cL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. '� <br /> Applicants Name (Print) 6 Title Ali Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information r <br /> 1. C3PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) k S V�{TIC UtO,'ER SERVICE <br /> For July 1, . June 30, 19 Disposal Sites ,,, w S�vCe4(j^ C2;rt o2J5 <br /> Description(Make/Yr., Color) ` l'',::�r s Lic.,� "] <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 <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 _ 1 <br /> Owner— <br /> Address s �'U 1" <br /> 1:1 SEPT TANK ❑ CESSPOOL LEACHING FIELD 0rSEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW RREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> '. <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 <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 /> t <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 rules and regulations of San Jo quip Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> SEPrIG & SE',VER SERVICE 3 <br /> 263 So. Oro _v Stccf,tan; Calif. 9521)51 <br /> FOR DEPARTMENT USE ONLY , <br /> v Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 <br /> 1:1 July 1 &Received By July 31 'E <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION A <br /> HATE DATE REMITTED MOUNT DUE CHECKED <br /> L ¢ / AMOUNT <br /> FEE <br /> LESS <br /> Y <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 4 <br /> OTHER <br /> S c fid; n <br /> Received by toate Receipt No. Permit No. Issuance Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />