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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> p APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicationij�jherelade to car on business in the l'ur dictional area of the n Joa in Local Health District <br /> n Business Name (DBA) 6.)4, fGit/l Ste. Address <br /> 10 <br /> z Owner Address <br /> I <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. 6 Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> Applicants Name (Print} E Title Date y <br /> Please check Applicable Category (1-7)and Fill In the Required Information -c <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 y <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 /> Tet ovation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/ ovation <br /> Owner — 4 /Q&t4.z Address f <br /> SEPTICTANK7 ❑ CESSPOOL LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT O <br /> PERMANENT ❑ TEMPORARY IX 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) t <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 rggvlations San Joaquin Local Health District. <br /> APPLICANT'S SIGNATU X <br /> 4z26 /9-Q LA <br /> FOR DEPARTMENT USE ONJY <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE 1:1EACH 0 January &R ed By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTAN' $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> (�C AMOUNT <br /> FEE 15 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> l5 `r v <br /> Received by Date Receipt No. Permit No. Issualrice Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 } <br />