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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 Lz is �r y m to n busin In he jurisdictional area of the San Joaquin Local Health Dis rict <br /> yBusiness Name (DBA) C!d � C- Address <br /> aOwners j. � r Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ?raIJJ6 Emergency Telephone No. R 7t <br /> Contractor Licence No. PAY <br /> Applicants Name (Print) S 6 Titled Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) W <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 <br /> 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 R.S. or R.C.E. No. <br /> Test Location Q Test Date/Time <br /> 4. X.6ANITATION PERMIT <br /> Job Address/Location 4 ,!!��.✓�x� - <br /> Owner ,.,A' <br /> Address �� `�� f <br /> ❑ SEPTIC TANK ❑ CESS OOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ,0.�,PERMANENT ❑ TEMPORARY INEW REPAIR VZ OTHER �7 X j (-2X/--2— lJ(} <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 /> O <br /> 1 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, an Vre3gIon of the San J quin cal Health District. <br /> APPLICANT'S SIGNATURE X <br /> Jora <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION �flr <br /> PLUS ' <br /> PENALTY <br /> R <br /> OTHER <br /> OTHER <br /> Cas <br /> Received by Date Receipt No. Permit No. fssuanc6 Date Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />