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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 /> Applicati by made c n business I jurisdictional area of San oaquin Lo al Health D'str t <br /> rn Business Name (DBA)���_i - —Addresst �P. � r <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telep neJNum rs <br /> aBusiness Telephone No. �✓� Emergency Telephone No. <br /> Contractor Licence No <br /> Applicants Name (Print) ]lA Title Date <br /> Please check Applicable Category (1=7)and Fill in the Required Information V <br /> 1. 13 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �, <br /> For July 1, June 30, 19 Disposal Sites <br /> i Description(Make/Yr., Calor) l/ <br /> Serial No. CAL. License No. CAL. Licc„se 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 <br /> t 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test <br /> rr�Location Test Date/Time <br /> 4. IKSANITATION PERMI <br /> Job Address cation <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ,R SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT © TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. © 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 /> 1 hereby certify that I have prepared this applica�*IQQ and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules an ion,((':)(t n Joaquin Local Health District. <br /> f <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 /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATEMITTED - AMOUNT <br /> k o <br /> F FEE <br /> LESS <br /> PRORATION <br /> ��IAA 1A1 <br /> PLUS <br /> PENALTY JI„ <br /> OTHER II <br /> OTHER - L <br /> Received by Date Receipt No. ermit o, I suan a at Mailed Delivered <br /> k. - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />