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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 is here ar busin ss the jurisdictional area of the S Joa ul ocal Heal h Dist ' t <br /> OF Business (DB.., � y�a S _ Addre`s� Q - <br /> aOwner l ------ Address_ -2 <br /> Firm Partners, Addresses and Telephone Numbers 4 — Y ff <br /> aBusiness Telephone No. �� Emergency Telephone No. <br /> Contractor Licence No. _x_ e <br /> L Applicants Name (Print)_W,C-S! Title 4040 d, Date 'Z doh. <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J ' <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) C' <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 /> SANITATION PERMIT <br /> Job Addres Location y�n 6P'-VL:z <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD © SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER l <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 /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location ff <br /> Plant Capacity No. Units Served i <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 /> T <br /> I hereby certify that I have d this applic on and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rul and . gulatio he n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> s <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1�&/Res ed By January 31' ❑ July 1 &Received By July 31 <br /> BILLING REMITTAN t�' + $ CHECKED <br /> REMIT <br /> BASE EXPLANATION DATE DATE l` REMITTED '`MOUNT DUE GHECiC <br /> AMOUNT <br /> 4 <br /> FEE <br /> LESS v <br /> PRORATION <br /> PLUS <br /> PENALTY �I <br /> OTHER <br /> OTHER <br /> i <br /> Received by- Date -- Receipt No. - Permit No. IPsuancle Datie Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />