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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is here ma rry on sine in a jurisdictional area of the Sa)r„l0aQuin cal Health District <br /> wBusiness Na DBA) Address /� <br /> aOwner t. a Address d 4 /16 r S <br /> Firm Partners, Addresses and Tele hone Numbers , cde 'r <br /> aBusiness Telephone No. 3 3�3� Emergency Telephone No. <br /> � Contractor Licence No. - I <br /> LApplicants Name (Print) I-C Title t1�Lit,� Date '�s' f <br /> Please check Applicable Category (1-7) and Fill in the Required Information -t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C� <br /> For July 1,..June 30, 19 Disposal Sites <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 <br /> 2. ❑ PUMPER YARD i <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> I <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 /> TestiLocation Test Date/Time <br /> 4. 9-So�ANITATION PERMIT <br /> Job Address/ ovation t <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD � EPAGE PIT ❑ PACKAGE PLANT Ch <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW W Rr--PAIR ❑ 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) <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 /> 1 hereby certify that I have pr ed this applicati and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rule nd regulations h an oaquin Local Health District. <br /> APPLICANT'S SIGNATURE 0 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due:'❑ ANNUALLY [I PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By J4r, ry 31 1:1Juiy 1 &Received By Ju hy 31 <br /> BASE EXPLANATION BILLING REMITTANCE REMIT <br /> AMOUNT DUE CHECKED <br /> DATE DATE R.MlT D AMOUNT <br /> FEE L <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER o <br /> 7) � I <br /> yrl <br /> i <br /> I <br /> Received by Date Receipt No. Permit No. ls�uance D to Mailed Delivered / k <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201. .i <br />