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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 /> Applicatio h reby m e t carry crousiness in the jurisdictional area of the San Joaquin Lo Health Di tric <br /> rn Business N me (DBA) Addr ss <br /> aOwner Address e-i <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. S�fFS -aG16 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) G L Title Sf� Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information �N <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) \ <br /> For July 1, June 30, 19 Disposal Sites �? <br /> Description(Make/Yr., Color) <br /> Serial No. - CAL. License No. CAL.ticcnse 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 I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name 3r R.S. or R.C.E. No. <br /> Test Location r r_ Test Date/Time <br /> t <br /> 4. ,+� SANITATION PERMIT <br /> Job Addr�As/,Location <br /> Owner T V'-, e ' e'ls/l7 Address ? �s <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 9 SEEPAGE PIT ❑ PACKAGE PLANT � � <br /> PERMANENT 11 TEMPORARY ❑ NEW CK REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 y <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 /> 9 <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, les and regulations of th San Joaquin Local Health District. <br /> } <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <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 /> BILLING - REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUECHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUSd <br /> PENALTY rAWAY <br /> + <br /> OTHER f <br /> OTHER .., ' <br /> Received by Date Receipt No. - Permit No Issuance Date Mailed Delivered <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCXTON,CA 95201 ' <br /> Thor r11IA - M <br />