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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 hereby made to carry on business in the jurisdictional area of the San quin L al Health District <br /> Business Name (DBA) Address_._ C� I7c A <br /> aOwner ,��_�_F/if/./ = Address i <br /> Firm Partners,Addresses and Telephone Numbers <br /> MCL <br /> Business Telephone No. 45 `i7Y Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) } t <br /> For July 1, June 30, 19 Disposal Sites .1 <br /> Description (Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse 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 <br /> Owner ' Address <br /> ❑ SEPTIC TANK ❑ CESSPOOLACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMP-ORA TNEyN" "' ❑ REPAIR ❑ OTHER /A ' <br /> 5. ❑ CHEMICAL TOILETS For JuYy 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 Y –' No.-Units-Served—­- <br /> 7. <br /> o.-Uni#s--Served------7. ❑ LAUNDRY For July 1, -June 30, 19 X. <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`wi#h San_Joa#quin County i <br /> ordinances, state laws, and rules and re I tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> +- 'FOR,DEPARTMENT USE ONLY <br /> � r <br /> Fee Is D e-❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑TEACH ❑ January 1 &Received By January 31 ❑ July 1 $ Received By July 31' <br /> REMIT - r <br /> BASE - EXPLANATION BILLING" REMITTANCE'DATE DATE REMITTED AMOUNT DUEZ.-GHECKED <br /> AMOUNT' <br /> csy <br /> LESS . <br /> "PRORATION <br /> PENAL-TN r r— � J <br /> i - <br /> 7 ^OTHER s <br /> OTHER <br /> Received by.. - Date - Receipt No�.., - Permit No. _ Wsuancb Date ,MailedDelivered <br /> APPLICANT-RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PI=RMIT/SERVICES-- - - i6DtE.HAZELTON AVE.,.P.O.Bow 2009 -STOCKTON,CA 95201 r <br />