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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - <br /> I APPLICATION <br /> ,' (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGP <br /> 2 LIQUID WASTE <br /> Application i re made t rry gp-bu ess in the jurisdictional area of the San Joaquin Lo lzFiealth 's rict <br /> FB Nam (DBA) Address -)r� <br /> z Owner �y � �/ � � - Address - <br /> Firm Partners, Addresses and T lephone Number <br /> aBusiness Telephone No. - .Emergency Telephone No. <br /> Contractor Licence No. "_ r _ <br /> Applicants Name (Print) - / Title Date I <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. <br /> 'I <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' <br /> R.S. or R.C.E. Name R.S. oe R.C.E, No. <br /> i <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Locafr n <br /> 1 <br /> �Owner t ess <br /> ;E—SEPTIC TANK ❑'CESSPOOL CEACHING F D ❑ SEEPAGE PIT C1 PACKAGE PLANT i <br /> .ERMANENT ❑ TEMPORARY ❑ NEW 94&EPAIR ❑ OTHER I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site j <br /> No. of Units 14 Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 - ' <br /> Operator Name k Where Certified <br /> Plant Location Z "s <br /> Plant Capacity ;- R' No. Units Served {T�+ <br /> 7. 11 LAUNDRY 'I For July-1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq, Ft:y 13 More Than 1,000 Sq. Ft. <br /> ❑ DRY GLEANING, Chemicals Used/Amount/Mo. <br /> ta'R <br /> F <br /> A - <br /> I hereb„ certify that I have r are his ) <br /> Y' c Y p p atio and that a work will be done in accordance with San Joaquin County <br /> ordinances`;state laws, and and r la ' ns of he San aquin L I Health District. <br /> APPLICANT'S SIG,ATUREX <br /> A. <br /> FOR DEPART4LY <br /> Fee Is Due: ❑ ANNU_ LY ❑'PER''17N1T, E1.,PER SITE ❑ EACanuary 31 ❑ July 1 &Received By July 31 <br /> «- }a. a. <br /> # BASE r EXPLANATION BILLING REMIT <br /> �' R * �; ,"` "'• DATEAMOUNT DUE CHECKED <br /> ` AMOUNT <br /> FEE. <br /> PESS <br /> RORATION <br /> PLUSH _..) <br /> PENALTY'"x K , <br /> El <br /> Yr <br /> OTHER s +a <br /> Received by Date - Receipt No. L Permit No. I IssusItice D to Mailed Delivered - <br />` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 1 <br />