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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 /> Applicatio 's by de t carry usin s 'n the jurisdictional area of the San Joaquin oval Health Dis t <br /> Businesss a JDB,A) ` Address <br /> a Owner /C t Z`�' � f��� Address 4Y (G Z//x}12 .&AN <br /> 1 Firm Partners, Addresses and Telephone Numbers l o� 4tSf& 77 1 'D-'1-// <br /> aBusiness Telephone No. 4!IP-A! 33 Emergency Telephone No. _<11 <br /> Contractor Licence No. �- <br /> L Applicants Name (Print) � Title 604)— Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, .lune 30, 19 Disposal Sites <br /> i <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 Test Date/Time <br /> 4. ❑ SANITATION PERMIT 1 r <br /> Job Addres ovation - <br /> Owner Address <br /> ❑ SEPTIC TAN CESSPOOL ACHING FIELD �EPAGE PIT ❑ PACKAGE PLANT -- <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW E3-`NEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction I Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July t, -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 /> hereby certify that I have prepared this appliciation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and r gulatio th an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Araz,_ 0 <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ! <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> Received by Date Receipt No. Permit No.- Muanc4 Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />