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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 1 <br /> LIQUID WASTEC <br /> Application is hereby made to on business in the jurisdictional area of the San Joaquin Local Health District �S� 7e- <br /> yBusiness Name DBA) a Address <br /> z Owner Address a _. <br /> Firm Partners, Addresses-and Tele hone Numbers �g <br /> ii � / � g C.r Y ��-Efnergency Telephone No. <br /> 5. Business Telephone No. <br /> _J Contractor Licence No. <br /> Applicants Name (Print) G�. itle — Date U <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., Calor) <br /> Serial No. CAL. License No. CAL. Lic:Esse Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address i <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 /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 9 SANITATION PERMIT �+-L }� X It <br /> Job Address/Location ,��f.�1y—_-�— d �Gs�' �� --Z� ler_ - '��9r. <br /> O_,, <br /> Address r <br /> OeSEPTIC TANK 13CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> t ❑ 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 O <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served A <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 /> _ 1 <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> r ordinances, state laws, and rules and regulations of the an Joaquin Local Health District. <br /> E � <br /> APPLICANT'S SIGNATURE X —, <br /> FOR DEPARTMENT USE ONLY <br /> I- Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 &Re January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION 6 <br /> PLUS <br /> ti <br /> PENALTY <br /> OTHER <br /> J OTHER <br /> it)04aD <br /> Received by - ate Receipt No. Permit ND. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />