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Applications Will Be Processed When Submitted Properly Completed. Be Sure To'Sign The Application.- <br /> AN '44 <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> r Application isJSreby mad carryon usiness in he jurisdictional area of the San Joaquin Local Health District f <br /> F Business Name (DBA) Address ri <br /> a Owner Address <br /> J Firm Partners, Addresses and Telep one Numbers <br /> CL Business Telephone No. ,A7 Emergency Telephone No. <br /> Contractor Licence No. <br /> dc Applicants Name (Print) d Title Date y ` <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, 1 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored i <br /> l � <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PER <br /> Job Addre s/Location 07 <br /> ;. <br /> O nerC A dress 2_0 <br /> SEPTIC ANK El CESPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKA LANT <br /> PERMANENT ❑ TEMPORARY NEW REPAIR El OTHER <br /> 5. 13 CHEMICAL TOILETS For July 1, - une 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: <br /> 11 Less Than 1,000 Sq. Ft., 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 Count <br /> ordinances, state laws, an les and regu tions of rnJo n Local Health District. y ++ <br /> APPLICANT'S SIGNATURE X 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By J a 31 ❑ July 1 &Received By July 31 <br /> BILLING _ REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMIT AMOUNT DUE CHECKED <br /> / AMOUNT <br /> FEE �d <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �• _� <br /> OTHER �� f <br /> OTHER r <br /> y <br /> CZ:2- a <br /> Received by Date Receipt No. - Permit No. Is uance to Ma d Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />