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I 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 <br /> LIQUID WASTE <br /> Appl ication�iieymade car on mess m the jur' dictional area of the San Joaquin Local Health DiIct <br /> OF Business Name %DB Address 7 O 7 <br /> z OwnerAddress—_.. . _ ___. <br /> rs — y <br /> a - <br /> Firm Partners, Addresses and Telephone Numbe <br /> CL <br /> Business Telephone No. .;ul? Emergency Telephone No. <br /> Contractor Licence No. Z-Z— r' <br /> L Applicants Name (Print) Title Date �� ^l�'d e, <br /> Please checkApplicable Category (1-7) and Fill in the Required Inform ion ` <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1� 51A. 'June 30,1,19 Disposal Sites <br /> Description(Make/Yr., Colof)* c <br /> Serial No. i CAL. License No. CAL. License Renewal No. <br /> Capacity ' Gal.,Weights & Measures No. , <br /> +Equipment Parking Address <br /> 2. ❑ PUMPER YA_RD <br /> e For July 1, June 30, 19 _ <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored x n <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. �. <br /> Test LL ation Test Date/Time <br /> 4. lu SANITATION PERMIT <br /> Job Address/Locati n - <br /> Owner Address77 lic <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD E�AGE PIT ❑ PACKAGE PLANT, F W <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW I[YFtEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> I Type Construction Disposal Site i <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 /> k Plant Capacity No. Units Served f01 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> k ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> F <br /> Y J <br /> I <br /> I I hereby certify that I have prepared this application and that the work will be done in accordanC4lvr?Ith'San Joaquin County <br />�. ordinances, state laws, and rules and r gulations of the S uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> v <br /> FOR DEPARTMENT USEO LY <br /> I Fee Is Due: ElANNUALLY ' ElPER UNIT ❑ PER SITE ❑ EACH ❑ Janu 1 ceived By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> SASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DAT REMITTED <br /> AMOUNT <br /> FEE l5 q5-2- <br /> PRO <br /> PRORATION <br /> PLUS <br /> PENALTY <br />. c <br /> OTHER r <br /> OTHER <br /> a <br /> { Received by - Date Receipt No. Permit No. 'Is'u ce to Mailed Delivered <br /> . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 601 E.HAZELTpN AYE.,P.O.Box 2009 STOCKTON,CA.95201. - <br />