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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 /> Application is hereby made 19 carry q#business in the jurisdictional area of the San Joaquin oval Hea h i rict <br /> ,n Business N me (DB ) Address 74' <br /> z Owner Address � <br /> D <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> o. Business Telephone No. ./ — v7 6 Emergency Telephone No. <br /> a Z5 � <br /> Contractor Licence No. <br /> Applicants Name(Print) Title Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites <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 N <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 t <br /> No. of Vehicles Stored V <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. t <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT ' <br /> Job Address/L ati In <br /> i <br /> Owner Address <br /> SEPTIC K 11 CESSPOOL LEACHING FIELD �9 SEEPAGE PIT ❑ PACKAGE PLANT <br /> *rPERMANENT ❑ 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 /> 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 r regulations of,the San Jo quip Local Health District. <br /> APPLICANT'S SIGNATURE X ` <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 & e d By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION <br /> BILLING REMITTANCE /1 $ REMIT <br /> DATE PATE REMITTED AMOUNT DUE CHECKED <br /> AM.OUNNTT <br /> FEECJ A <br /> v <br /> LESS 1 <br /> PRORATION <br /> PLUS ' <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a I 12n .� <br /> Received by Date Receipt No. Perrut No. Is uance Date Mailed elive d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOOkTON,Z.5101 <br />