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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 /> �(DBAM <br /> ¢ceby de tp Carry on bu ess int a jurisdictional area of the San Jo�uln_L^ocal Health Dist rl t <br /> w Business Name — v �" /���� Address��t?-S ���T <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telep ne Numbers <br /> 0. Business Telephone No. f Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) /t'f Title Date <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. Liccnse 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 TESTQ`'V_ <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. iJ' <br /> Testi Location Test Date/Time \\ <br /> 4. Th(SANITATION PERMIT <br /> Job Address/Location <br /> OwnerD-00W Address t) C / S' l�C"l T <br /> 9 SEPTIC TANK ❑ CESSPOOL EgLEACHING FIELD j9SEEPAGE PIT ❑ PACKAGE PLANT <br /> 19 PERMANENT ❑ TEMPORARY 1W NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <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 /> Plant Capacity No. Units Served <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. <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 ws, n les and regulati �Ofthe Joaquin Loca Healt istrict. <br /> APPLICANT'S SIGNATURE X P '� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT X'PER SITE ❑ EACH ❑ January 1 &Received By, ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCEREMIT <br /> BASE EXPLANATION DATE DATE REMI ,D UNT DUE CHECKED <br /> ' <br /> AMOUNT <br /> FEE <br /> FEE yJ , `T LJ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 1 <br /> OTHER <br /> Received by Date Receipt No. Permit No. I#suancd Date Mailed 1,Delivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA 95 1 <br />