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Applications Will Be Processed When Submitted Properiy Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is ebymade toprry on business in the ju isdictional area of the San Joaquin Local Health Distric <br /> . r Business Name (DB ddress <br /> aOwner Address ' <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �� & � Emergency Telephone No. } <br /> Contractor Licence No. 2 <br /> �Applicants Name (Print) i Title Date <br /> r Please check Applicable Category (1-7)and Fill In the Required Into. ation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19Disposal Sites <br /> F Description(Make/Yr., Color) iM <br /> I Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity i� Gal„ Weights & Measures No. ? <br /> I 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 /> t 3. ❑ PERCOLATION TEST <br /> f R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Lo on l`� Test Date/Time <br /> U <br /> 4. SANITATION PERMIT �I r <br /> Job Address/Lo n �' Z' — <br /> j Owner Address r— <br /> ❑ SEPTIC TANK CESSPOOL EACHING FIELD B SEWAGE PIT ElPACKAGE PLANT <br /> ElPERMANENT ❑ TEMPORARY ❑ NEW EP_AIR E] OTHER Q <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 "' I <br /> fi Type Construction Disposal Site. <br /> No. of Units Equipment Storage/Clean-ing Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30—, 19 <br /> j Operator Name ji, _ Where Certified <br /> Plant Location <br /> Plant Capacity �I° No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -Jeune 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq:I�Ft.,- ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> I hereby certify that I.�nave prepar this application and that the work will be done in accordanc�wri h San Joaquin County <br /> ordinances, state Iaws-�and rul d regulations of the%A Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ON . <br /> I Fee IS Due: ❑ ANNUALLY I� ❑ PER UNIT ❑ PER SITE n, ❑ EACH ❑ Ja a y 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING R NCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> I, I DATE ATE REMITTED LI AMOUNT <br /> r FEE l 1 _ , <br /> LESS I� <br /> PRORATION <br /> PLUS I <br /> PENALTY <br /> r <br /> OTHER �� y <br /> OTHER <br /> !L <br /> 1� �� r Ian -111,3186 <br /> Received by ' Date Receipt No. Ir Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTOIN AVE.,P.O.Boz 2009 STOCKTON,GA 95201 <br />