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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> fA 4v (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> i <br /> LIQUID WASTE <br /> Application i ereby made to carry on bLisiness in the'uris tional area of the San Joaqui Local Health District <br /> rn Business Name ( A, Address �� _2_4.7 <br /> r z Owner Address <br /> 6 a <br /> .Firm Partners,Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. .316$ I/'0 Emergency Telephone No. <br /> Contractor Licence No. �- <br /> Applicants Name (Print) Title Date <br /> Please check ApplicableCategory (1-7)and Fill in the Requirell 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. <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 /> G R.S. or R.C.E.Name R.S. or R.C.E. No. <br /> Test Lation Test Date/Time <br /> I 4. a SANITATION PERMIT <br /> I. <br /> Job Address/Location �2 31 57 _ <br /> O er Address , �� ��are <br /> 0SEPTIC T K ❑ CESSPOOL MLEACHING 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 f�1 <br /> G No. of Units Equipment Storage/Cleaning Location(s) -. <br /> 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 /> 4 I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state.laws,;Cdles 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 R FleceNed By January 31 ❑ July 1 &Received By July 31 <br /> ZAMOUNT <br /> BILLING REMITTANCE $ <br /> ` RASE EXPLANATION PATE DATE REMITTED AMOUNT DUE <br /> FEE 5 <br /> LESS (4j,l <br /> r PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER f / j 01 <br /> Received by - Date Receipt No. - Permit No. - Is uanc Da - Mailed Delivered - <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 .HA2ELTON AVE.,_.a.Box 2009 STOCKTON,CA 95201 - <br />