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Applications Will Be Processed When Submitted Properly Completed. BeSureTo Sign TneApplication. <br /> APPLICATION <br /> j (For Non-Transferable, Revocable, and Suspendable) <br /> r <br /> ENVIRONMENTAL HEALTH PERM1 }� '' SEPTAGE <br /> LIQUID WASTE <br /> Applicatio is heretly made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> NBusiness Name (DBA) A, HiQ C Address <br /> aOwner. Address <br /> o Firm Partners, Addresses and Telephoonnee Numbers iq <br /> aBusiness Telephone No. - �r Emergency Telephone No. <br /> t -i Contractor Licence No. s <br /> Applicants Name (Print) s��'���-may. ��— � Title <br /> F Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> E For July 1, June 30, 19 Disposal Sites <br /> ti <br /> ` Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL, License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> r Equipment Parking Address <br /> J. 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> � R.S. or R.C.E. Name <br /> R.S. or R.G.E. No. <br /> Test�Location Test Date/Time <br /> E <br /> 4. SANITATION PERMIT <br /> Job Address/Location � � �'�iv�S�Is�J C <br /> O,wnnee �ee������5 - Address <br /> SEPTIC TANK C1 CESSPOOL ❑ LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE.PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 2'NEW ,-. REPAIR ❑ OTHER <br /> l 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> Equipment Stora Storage/Cleaning Location(s) z <br /> No. of Units9 9 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name r Where Certified <br /> Plant Location <br /> i Plant Capacity �I 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 /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> hereby certify that I have repared this application and that the work will be done in accordance with San-Joaquin County <br /> ordinances, state iaws,.a rul s and re ations of he Sa oaquin Local Health District. <br /> - A - <br /> APPLICANT'S SIGNATURE X <br /> 3 <br /> k. <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 /> l BASE EXPLANATION KILLING REMITTANCE $ _AMOUNT DUE CHECKED <br /> DATE DATE - REMITTED AMOUNT <br /> O <br /> FEE �. <br /> LESS <br /> PRORATION v <br /> PLUS <br /> PENALTY - <br /> OTHER / <br /> OTHER ^ <br /> 7! <br /> r... - Received by Date Receipt No. Permit No Issuance Date Mailed Deliv - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />