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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 <br /> LIQUID WASTE <br /> Application is y made to y7ry on business in the jurisdictional area of the San Joa uin Local Health Distric <br /> F Business Name (DB 140 O Address <br /> oj— <br /> a Owner �✓[_ Address U a <br /> J Firm Partners, Addresses and T le hone Numbers p�� <br /> aBusiness Telephone No. 1 ..C,� <br /> Emergency Telephone No. <br /> � Contractor Licence No. Z. <br /> L Applicants Name (Print) Title Date j <br /> Please check Applicable Gategory (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. # s <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD t <br /> For July f, 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 ocation Test Date/Time <br /> 4. 4 SANITATION PERMIT <br /> Job Address/Loc i.on <br /> Owner LU NA AddresSEPTIC TANK ❑ CESSPOOL 11 LEACHING FIELD Cl SEEPAGEPIT ❑ PACKAGE PLANT " <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR 'z . I # ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS ForlJuly 1, -June 30, 19 ""^ <br /> Type Construction Disposal Site =' -� -. - - <br /> No. f Units Equipment Storage/Cleaning Location(S) <br /> 6. PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name `r <br /> Plant Location Where-Certified <br /> Plant Capacity t <br /> �`No. Units Served � <br /> 7. ❑ LAUNDRY For July 1, - <br /> 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 /> Y , <br /> f I <br /> I hereby certify that I have-prepared,this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,'a' rules and re uons o the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 7� <br /> L <br /> ' FOR DEPARTMENT USE ONLY 9t <br /> Fee IS Due: ❑ ANNUALLY 4❑ PER-UNIT--[] PER SITE 4 ❑ EACHd <br /> ❑ January 1 8 Received By January 31 ©July 1 &Received By Juiy 31 <br /> BASE EXPLANATION BILLING REMITTANCE :$. REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE qs <br /> LESS <br /> PRORATION <br /> PLUS -.. .-- <br /> PENALTY ,tet <br /> G .r <br /> OTHER <br /> OTHER <br /> Received ny Datee mit N <br /> P <br /> Receipt No. - ero. Issua cDate'" <br /> � .. _ Mailed Delivered - <br /> -APPLICANT—RETURN ALLCOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601E.HAZELTON AVE.,P.O.Box2009 STOCKTON,CA 95201 /` <br />