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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 /> 1 LIQUID WASTE _ <br /> Application is hereby made�to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) a.- 4'£' Address <br /> c a Owner '� Address '- <br /> k Firm Partners, Addresses and Te ephone Numbers <br /> aBusiness Telephone No. �3 --7 Emergency Telephone No, <br /> Contractor Licence No. <br /> LApplicants Name (Print) e'er Title C Date <br /> I 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 /> t <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 A <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 /> 4. WSANITATION PERMIT��,,,�� � { <br /> Job Address/Location <br /> Owner d Addres ' <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 /> 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 /> I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. { <br /> . 1 <br /> I <br /> r <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 r an egulations of the San Joaquin Local Health District. y <br /> APPLICANT'S SIGNATURE X fiC +e <br /> FOR DEPARTMENT USE ONLY j <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> AMOUNT-DUE CHECKED ' <br /> 0 DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ` <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER tt II <br /> I <br /> T Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009. STOCKTON,CA 95201 <br />