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Applications Will Bd 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 /> Application 's hereby mac to carry on siness in the juri dictional area of the San Joaquin Local Health istrict <br /> H Business Name A) �+ �, .,/Address <br /> �� 7G <br /> aOwner Address { rs±)Z1�76"7 -- <br /> J Firm Partners, Addresses and Telephone Numb rs <br /> aBusiness Telephone No. Emergency Telephone No. <br /> l Contractor Licence No. _ <br /> f Applicants Name (Print) Title Date �— <br /> Please check Applicable Category(1-7) and Fill In the Requi ed Information <br /> 1 1.- ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i For July 1, June 30, 19 Disposal Sites .r <br /> t <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc-lse Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> 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 /> 3. ❑ PERCOLATION TEST F <br /> R.S. or R.C.E. Name R.S. or R.C.E. No- <br /> Test L tion Test Date/Time f <br /> 4. L`J SANITATION PERMIT <br /> Job Address/ ocation _ifgpe <br /> OwnerAddress 1 5- <br /> 47 <br /> ❑ SEPTIC TANK ❑ CESSPOOL 11 LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT (IJ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 81REPAIR ❑ OTHER <br /> l 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 4) i <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location ` <br /> Plant Capacity No. Units Served <br /> i 1 <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. 11 <br /> I hereby"certify'that l have prepared this application and that-the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and regulations f t e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑'January I &Received fay January 31 ❑ July 1 &Received_By July 31 <br /> --+w. REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> i I AMOUNT <br /> FEE <br /> 4r <br /> I LESS 1 <br /> PRORATION fit <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> t OTHER - _-+n_ _ - _ -• m .r.--F. _ _ __� <br /> 141 <br /> Received by Dat Receipt No,. "'' Permit No,j �' I iss ance-Date ' Marle y Delivered <br /> APPLICANT-RETURN ALL COPIES TO�ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E..HAZELTON AVE.,P.O.Bow 2909 STOCKTON,CA-95201 - ' <br />