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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> }7►,^ APPLICATION <br /> -7 (For Non-Transferable, Revocable,and Suspendable) SEPTAGC <br /> 9 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE (10 <br /> Applicati herebyamad to car on busi ess in a jur'sdict na�rea of the Soa uq Iy,Loca�H�ealth i rict <br /> ,BusinessFtige (DBA dress �/� <br /> I`_ Owner Address a~� <br /> a <br /> U Firm Partners, Addresses and elep one umbers <br /> a business Telephone No. r 5^I Emergency Telephone No. <br /> Contractor Licence No. <br /> Date <br /> I Applicants Name (Print) <br /> �- Title <br /> Please check Applicable Category�(1-7)andFilljri�atq�uledlnfomstion <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 [,3 <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 Dation Test Date/Time <br /> 4. V SANITATION PEERRMII ! } f Ill 0,91 <br /> +' 4 <br /> Job Addre /Lo ati (p <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD"'" SPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 0 NEW „d E REPAIR ❑ OTHER + <br /> 5. 1:1 CHEMICAL TOILETS For July 1, -June 30, 19 �+ <br /> i`�'•Di <br /> Type Construction Disposal Site_ � <br /> No. of Units i_ Equipment Storage/Cleaning Location(s) <br /> 6. 13PACKAGE TREATMENT PLANT, For July 1, Juune 30, 19A- <br /> Operator Name y _ E 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. Ftt.�_'L <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, an rules an reg lations of the San Joaquin ocal Ith District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT US <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ J uary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING RE TANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER e <br /> Received by Date Recei o. Permit No. I Issuance Date - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: E VIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO ,CA 95261 <br />