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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. x <br /> APPLICATION <br /> - L (For Non-Transferable, Revocable,and Suspendable) <br /> _ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i ere¢y ma e t carryon business in the j isdictional area of the San Joaquin Local Health Dis ict <br /> Business Name A) 2 Address O-64 ? <br /> aOwner Address -- -..-�-- <br /> J Firm Partners, Addresses and Telephone Num <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. —� k <br /> Applicants Name (Print) _ Title Date <br /> Please check Applicable Category(1-7)and Fill inthe Req�edformation <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 /> i <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. r <br /> Test Lobation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Lipication <br /> Owper Address -99:W cf �8 <br /> I SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD E]XEPAGE PIT 11PACKAGE PLANT + <br /> 1:1PERMANENT ❑ TEMPORARY 11NEW IEf 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 /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 t <br /> ordinances, state laws, and rul and regulations of the San Joaquin Local Health District, j <br /> i <br /> APPLICANT'S SIGNATURE) <br /> } <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION - DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUN11 <br /> FEE ( /� <br /> LESS �l <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER r <br /> Received by r_ pate Receipt No. Permit No ilssuando Date Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1661 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 y <br />