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-—•-Applications Will Bi Processed When Submitted Properly Completed. Be Sure To Sign The Applieation. <br /> APPLICATION - • , t <br /> ? h (For Non-Transferable, Revocable, and Suspendable) _.•, <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE —1 <br /> r __'LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name (DBA)-4 S " e- .,i S-- -aAddress Z2-r_iff._Moge sT fit/ <br /> i Owner <br /> C - Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. Emergency Telephone No. <br /> t Contractor Licence No. <br /> L Applicants Name (Print) Title . 97W+vie 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 I Disposal Sites <br /> Description(Make/Yr., Calor) I <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 /> k For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST l <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> i <br /> Test Location Test Date/Time i <br /> 4. JK SANITATION PERMIT <br /> Job Address/Location SO 0_0-z- _T_ <br /> Owner A Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD J SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW 'p""�� REPAIR ❑ OTHER <br /> S. ❑ 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 i- <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. FL, ❑ 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 rules and regulations of th Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 7t1t 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 *EI$TTED <br /> REMIT 1 <br /> RASE - EXPLANATION DATE DATE AMOUNT DUE CHECKED f <br /> AMOUNT F <br /> FEE �LESS �� <br /> PRORATION t <br /> PLUS l k <br /> PENALTY <br /> OTHER ! r I� <br /> OTHER ` <br /> Received by - Date - Receipt No. Permit No Issuance Date Mailed elivOed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA.95201 <br />