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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 i her by m de to car n business in the jurisdictional area of the San J iquin Local Health <br /> >District _ <br /> ,T-Business Name (DBA) `�l 2'r" Address �� 3',�_! -- <br /> z Owner_ . +/LL Address <br /> a <br /> J Firm Partners, Addresses and Tel hone Numbers <br /> m Business Telephone No. 57-/ Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) - 4, G L 4 Title e-_%, 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, 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 A Test Date/Time <br /> 4. ❑ SANITATION PERMITie r--- <br /> Job Address/Location � '�' <br /> Own TL6 If �.Q1Z1 �j Address 4 <br /> EPTIC TANK �❑ CESSPOOL -P-rEACHING FIELD ❑ 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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 119 <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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regu tions of the San Joaquin Local Health District. F <br /> APPLICANT'S SIGNATURE X ldr <br /> FOR DEPARTMENT USE ONLY 'r <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1 &Received By Janbary 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 f� <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 107� � LS r� <br /> Received by Date Receipt No. Permit No. 1ssuanft Datla Mailed Delivered z <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA$5201 <br />