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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 /> J Application ' ereby mad carr on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,r Business Name (DBA} Address <br /> aOwner A — Address d <br /> Firm Partners, Addresses and Telephone Numbers „�r 1._� ll?n <br /> 0. Business Telephone No. _k-G <br /> a ^ . - _ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title 9;a j _ Date 7 <br /> 1 ky <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. Liccase Renewal No. z <br /> Capacity =- Gal., Weights & Measures No. ' <br /> Equipment Parking Address. <br /> 2. ❑ PUMPER YARD T 4 # <br /> For.July 1, June 30, 19 4 <br /> No.'of Vehicles Stored <br /> No. of Chemical Toilets Stored § #r <br /> 3. 11 PERCOLATION,TEST � <br />` R.S. or`R:C.E._Name_ R.S. or R.C.E. No. ` <br /> Test Lo Ion ""'= "�"" ' Test Date/Time j i <br /> 4. VSANITATION PERMIT ' <br /> Job Address/L ation <br /> Ow,�s Die -c Address w V' p <br /> ,t7 S TANK ❑ CESSPOOL LEACHING FIELD ❑ PACKAGE PLANT ; <br /> @-'PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,i June 30, 19 <br /> Type Construction t Disposal Site i <br /> No-!of Units EquipmentStorage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July.1, -June 30, 19 <br /> Operator Name f Where Certified L4 1 <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> V E <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r} <br /> ( 4 l <br /> I hereby certify that l have prepared this application a at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r es and regulations oft San aquin Local Health District. <br /> APPLICANT'S SIGNATURE X 3 <br /> r � 1 + <br /> � F <br /> l <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT _ ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 <br /> f BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION GATE DATE REMITTED <br /> AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> F <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY s <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. - Permit Na_ ;, � - <br /> p -_ „��,�Issuance•Date.... Mailed Delivered <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE.,R.O.'BOx 09/. STOCKTON,CA.95201 <br /> 7 <br />