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• Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> " LIQUID WASTE <br /> Application ' hereby m e to carry on business in the jurisdictional area of the San Joa ui °cal Balt pis r t <br /> rn Business Name (DBA) Address _ ' a a C <br /> aOwner Address — <br /> M Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. 2 Emergency Telephone No. i <br /> 1 Contractor Licence No. _ <br /> Applicants Name (PrintTitle Date <br /> Please check Applicable Category (1-7) and Fill in the Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f` <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) j <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity Gal., Weights & Measures No. i <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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMI <br /> Job Add r /Location <br /> Owner Rcldress Z54) <br /> SEPTIC TANK Lb CESSPOOL ❑ LEACHING FIELD— ❑ SEEPAGE PIT. -•❑ PACKAGE PLANT , <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> �r <br /> Type Construction Disposal Site ;4,v <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 l <br /> Operator Name Where Certified <br /> Plant Location k <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 prepared this application and that the work will be done in accordance with Sah Joaquin County <br /> ordinances, state laws, a ules and reglatio of the San Joaquin Local Health District. t <br /> Y <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> a <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 F <br /> BILLING REMITTANCE $DATE PATE REMITTED REMIT <br /> f <br /> BASE EXPLANATION kl� AMOUNT DUE � CHECKED <br /> AMOUNT <br /> FEE �L�S � <br /> r <br /> LESSi <br /> PRORATION (, <br /> i <br /> PLUS - ) <br /> PENALTY (`" A. <br /> - - <br /> OTHER <br /> OTHER C <br /> Received oy Nate Receipt No. Permit Na. Issuance Date - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIAONMENTAL HEALTH PERMITfSERVICES - 1601.E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />