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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 /> t Application is hereby mad to carry on business in the risdictional area of the San Joaquin Local Health Di trict <br /> F- <br /> Business Name (DPA) ��> t Address e 0,1+ '7k 7 <br /> aOwner Address � ^---��`- <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. ID Emergency Telephone No. <br /> i _j Contractor Licence No. �- <br /> Applicants Name {Print) Title Date <br /> f Please check Applicable Category(1-7)and Fill in the Required Information cO�C <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites 1 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc:lse Rere<wal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> f 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> i 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 LLaation Test Date/Time <br /> 4. SANITATION PERMIT p <br /> Job Address/Location <br /> Owner Address 4eCry <br /> ❑ SEPTIC TANK M CESSPOOL LEACHING FIELD ❑ IT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW �{EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 C\1 <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 /> c Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I] DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <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, andrul and regulations the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X — <br /> i <br /> L 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 /> s- $ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> I <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> ' PENALTY <br /> i OTHER <br /> OTHER <br /> VS <br /> Received by - Date Receipt No Permit No. Issuance D Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTO .O.Box 2009 STOCKTON,CA 95201 <br /> n l �' <br />