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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE ' <br /> LIQUID WASTE <br /> Application is here y m de to carry on business in the jurisdictional area of the San aquin Local Health District <br /> yBusiness Name (DBA) i'"c:�'�� 2 Address�� �` f ���� `� <br /> z Owner ✓r' Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> C6 <br /> Emergebc TelePhone N <br /> Business Telephone No. ~! oe <br /> a <br /> a } <br /> _J Contractor Licence No. <br /> L Applicants Name (Print) ,�- - ��C�� Title r. Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information r t � ; U� <br /> 1. 13 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) a - <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) ''". •° <br /> Serial No. CAL. License No. CAL. L{cc_iae Renewal No. hIy <br /> Capacity Gal„ Weights &Measures No. y 9 <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. [1 PERCOLATION•TEST t <br /> • <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION.PERMI,T _ ) <br /> Job Address/Location—_-.._._____- ,i ce L.r�� ��� q�_�V2y P ' <br /> Owner Address. -_3 <br /> ❑ SEPTIC TANK ❑_CESSPOOL ❑ LEACHING FIELD E] SEEPAGE PIT ❑ PACKAGE PLANT <br /> © PERMANENT 13TEMPORARY ❑ NEW ❑ REPAIR OTHER <br /> S. ❑ 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 /> 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 regul 'ons the Sa quin Local Health District. <br /> rY <br /> APPLICANT'S SIGNATURE X — .-- <br /> F r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY "92PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received#3y January 31 .❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> SASE { EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT 1 <br /> FEE <br /> LESS 7 <br /> PRORATION P <br /> PLUS ° <br /> —PENALTY <br /> k <br /> OTHER <br /> OTHER <br /> S1 11 <br /> Received by Date Receipt No. Permit No. IsTsurancd Date 1 'Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVEI.P.O.Bow 2009 STOCKTON,CA 95201 <br />