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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 he by made to c rr n business the jurisdictional area of t San Joaquin Local Health Distrifct�1 <br /> m Business Name (DBA)' -� 1511 s�-..I-�'`�� .. Address V0 +4�0 .SMS/" • G6wl !!! <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and elehone Numbers <br /> aBusiness Telephone No. � " Emergency Telephone No. <br /> Contractor Licence No. r <br /> L Applicants Name (Print) Title 1 Date <br /> Please check Applicable Category(1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, F June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No, CAL. Licc,7se 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 /> i 4,_VSANITATION PERMIT /' " N.� <br /> Job Addregs/Loocatioon_ �_ �_� � �S L�Q[71.1� t <br /> Owner M12.`-CA29 1 17W Address <br /> A(SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT J❑ TEMPORARY ❑ NEW ❑ THER REPAIR O <br /> t <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 /> I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1;-June 30, 19 <br /> Operator Name s Where Certified <br /> Plant Location <br /> Plant CapacityNo. Units Served <br /> E r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. j <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 San Joaquin County <br /> ordinances, state laws, and rules and ulatiq s C t San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑,January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING RE TTANCE $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT i <br /> FEE <br /> LESS ' 4 <br /> PRORATION <br /> PLUS <br /> PENALTY f <br /> OTHER r <br /> i &HER �mow•-.,. - - <br /> Received by Date Receipt No. Permit No. Issuance Q to a tl Delivered <br /> " APPLICANT—RETURN ALL C_OPIES.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P, . oK 20109 STOCKTON,CA 95201 <br />