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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 's her by rAacle to on ziness in the jurisdictional area of th an Joaquin Local Health District <br /> car <br /> FBusiness Name (DBA) .. b f Address Ed 842,K <br /> a Owner Address <br /> i 9 Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print) C/ Title CST pate <br /> Please check Applicable Category,.(1-7)and Fill in the Required Information 1 <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 e <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. G <br /> Test Location Test Date/Time ' <br /> 4. 19 SANITATION PERMIT <br /> Job Address/Location �L p .14` N <br /> Owner 7 Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER .5 <br /> f 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Q <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: ❑ 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 County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 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 /> i BILLING REMITTANCE. $ REMIT <br /> BASE.. EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> f FEE ,� Ch <br /> LESS <br /> PRORATION j (� <br /> PLUS V, <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> p -•;. Receipt No - - Permit Mo. Issuance Date Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />