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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .a <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is ereby�made to rry on business in the'unsdictional area of the San oaquin Local Health District <br /> �;Business Name (DB ) <br /> aOwner cAddress <br /> Firm Partners, Addresses and Telephone Numbers Address <br /> aBusiness Telephone No. <br /> Contractor Licence No. Z_ Emergency Telephone No. <br /> a <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information Title �L.� Date <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) Disposal Sites <br /> Serial No. <br /> Capacity CAL. License No. <br /> Gal., Weights &Measures No. CAL. License Renewal 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 <br /> R.S. or R.C.E. Name <br /> Test;LLo ation R.S. or R.C.E. No. <br /> 4• SANITATION PERMIT Test Date/Time <br /> Job Address/ cation Z- 7 1 <br /> Owner —4-d- <br /> ❑ SEPTIC TANK ❑ CES OL ❑ Address J— <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEw LEACHING FIELD ❑ PACKAGE PLANT <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 REPAIR ❑ OTHER <br /> Type Construction <br /> No. of Units Disposal Site <br /> Equipment Storage/Cleaning Location(s) <br /> s• ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Plant Location Where Certified <br /> Plant Capacity 14) <br /> 7. ❑ LAUNDRY For July , -June 30, 19 1No. Units Served <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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, and rules an egulations of the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT <br /> ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar 31 <br /> BASE y ❑ July 1 &Received By July 31 <br /> EXPLANATION BILLING REMITTANCE <br /> DATE $ REMIT <br /> FEE DATE REMITTED AMOUNT DUE CHECKED <br /> MOU <br /> LESS If <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 1 <br /> OTHER <br /> Received by <br /> Date Receipt No. 4(J• e� ` <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESIssua ce Dat <br /> Mailed elivered <br /> 1601 E.HAZ LTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />