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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 i rebyTmade to arty on buess i the uric ictional area of the Sa Joaquin Local Health Distri <br /> Business Name Addr ss +76 2 <br /> aOwnerAddress <br /> J Firm Partners, Addresses and Telephone umbers <br /> aBusiness Telephone No. 36 g 51C S Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in t�ReqEedinformation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �, <br /> For July 1,''�°�� 1-une 30, 19 Disposal Sites <br /> Description(Make/Yr.,-Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity F Gal., Weights & Measures No. • <br /> Equipment Parking Address 3 <br /> 2. ❑ PUMPER YARD T For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> - w 1 <br /> 3. ❑ PERCOLATION TEST t? { <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Kation Test Date/Time i <br /> 4. IBJ SANITATION PERMIT w � <br /> Job Address/Location � � <br /> Owner '2 Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW EPAIR ""`-❑'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 /> 5. 'Q PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r <br /> Operator Name *Where Certified <br /> Plant Location <br /> Plant Capacity No. Unit Served <br /> Ij <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft„ ❑ More Than 1,000 Sq. Ft. I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. i <br /> I hereby certify that I have prepared this application and that.the work will be done in accordance with San Joaquin unty <br /> ordinances, state laws, and ruleS4nd regulations ofSan Joaquin Local Health District. i <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:.0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Teiv�eRy anuary 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCEREMIT <br /> BASE EXPLANATION DATE DATE AMOUNT DUE CHECKED <br /> AMOUNT <br /> y O <br /> FEE <br /> LESS [ <br /> PRORATION ` <br /> PLUS i1 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No 'IssuaInce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />