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Applications Will Be Processed When Submitted Properly Completed. 9e Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br />`€/ Appl ication is hereby made to carry on business in the ij irisdictiona!areaof th an Jo On Local Health District r <br /> yBusiness Name (DBA) Address <br /> z Owner <br /> a Address CR ey, <br /> J Firm Partners, Addresses and Telephone Num ers <br /> a Business'Telephone No, <br /> I Emergency Telephone No. <br /> Contractor Licence No. 'Z <br /> L Applicants Name (Print) Title Date / 8 t . _ 1 <br /> Please check Appllcabie Cat ry (1-7) and Fill in the F61quired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) oG <br /> For July 1,._ -June 30, 19 Disposal Sites r <br /> Description(Make/Yr., Color) <br /> Serial No CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address I <br /> 2. ❑ PUMPER YARD <br /> For July i, June 30, 19 k <br /> No. of Vehicles Stored `. <br /> No- of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST y <br /> R.S. or R.C.E. Name _ R.S. or R.C.E. No. <br /> Test Lo tion Test Date/Time <br /> 4. SANITATION PERMIT <br /> v r <br /> Job Addr /Location <br /> s <br /> Owner 0Lk C4 <br /> -4 Address ! <br /> rP'SEPTIC TANK . CESSPOOL- ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ®'15'ERMANENT ❑ TEMPORARY ❑^IGEW ❑ REPAIR %-Z5THER SUiY1� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) j <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location k <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 f <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t. <br /> F <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, rules and ulat' ns of the San Joaquin Local Health District., <br /> APPLICANT'S SIGNATURE X <br /> Y t <br /> 1 <br /> v 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 j <br /> BASE EXPLANATION BILLING REMITTANCE t_} $ REMIT <br /> AMOUNT DUE CHECKED <br /> ` DATE ,,,.,..-... DATE i REMITTED <br /> - ""- AMOUNT <br /> FEE a F <br /> t <br /> LESS It <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 4 <br /> 1 I <br /> Received by Date Receipt No. Permit No. I suance Date Mailed Delivered <br /> -APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95!201 <br /> - I <br />