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Applications Will Be Processed When Submitted Properly Completed. tae Sure To Sign The Application. <br /> APPLICATION J <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE - <br /> LIQUID WASTE 0 r <br /> Ap-plicatiiooan is h reby ,ade carry b i ss in the jurisdictional area of the S Joa Local Health strict <br /> F Business a (DBA) Address <br /> i Owner i E Address dA <br /> a p L 3 <br /> 0 Firm Partners, Addresses an Telephone Numbers a <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. .� <br /> L Applicants Name (Print) <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., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. w <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD . . ._� <br /> For July 1, June 30, 19 r i <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/TimeG! <br /> , <br /> 4. O'SANITATION PERMIT <br /> Job Addre / ocation Q YJ6 Al, <br /> Ovy�er Address <br /> SEPTIC TANK ❑ CESSPOOL ffLEACHING FIELD ❑ SEEPAGE PIT. ❑'PA'CKFiGE PLANT <br /> wow <br /> 9'PERMANENT ❑ TEMPORARY G��NREW ❑ REPAIR ❑ OTHER' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r <br /> Type Construction Disposal Site — <br /> No. of Units Equipment Storage/Cleaning'Location(s) J., _- — <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r <br /> Operator Name 4 Where Certified <br /> Plant Location <br /> Plant Capacity No7 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 /> e <br /> I hereby certify that I have pr ,re is applic to d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and les d regulation Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> J <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 /> BASE EXPLANATION BILLING REMITTANCE, $ REMIT <br /> °. AMOUNT DUE- CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE u'vS <br /> LESS —[ <br /> PRORATION <br /> PLUS <br /> PENALTY `'• $�� 1 <br /> OTHER <br /> OTHER <br /> S 71 `31 <br /> Received by Date Receipt No Permit No. Imu nce D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.'HAZELTON AVE.,P.O.Box 2008 STOCKTON, 5201 <br /> b k/I ryy . <br />