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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> ; <br /> APPLICATION f <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> !1 Application ' hereb4y made t car on b ' ess in the urisd' tional area of the,S<l Joa uin Local Health District <br /> rn Business Name A) Address <br /> aOwner Address J d <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. ] Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Applicants Name (Print) Title " Date 1 <br /> PleaseIcheck 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 /> Equipment Parking Address <br /> 2. ❑PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. ofd Vehicles Stored <br /> No. of,,Chemicai Toilets Stored <br /> 3. �PERCOLATION TEST w <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. 1 <br /> Test L� ation Test Date/Time <br /> 4. (SANITATION PERMIT <br /> Job Address/L cation <br /> Owner Address <br /> ❑ SEPTIC T K 11 CESSPOOL El LEACHING FIELD EEPAGE PIT El PACKAGE PLANT <br /> 11 PERMANENT [] TEMPORARY ❑ NEW 51PAIR ❑ OTHER [�J . <br /> 5. ❑lkCHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of"l nits Equipment Storage/Cleaning Location(s) . <br /> 6. ❑PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name it Where Certified <br /> Plant J}ocation h <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 4 <br /> SIZE: I ❑ Less Than 1,000 Sq. Ft. ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. t <br /> i <br /> k <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 r and regulations of the 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 1 &Received By January 31 C1 .1Wy 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> ]EA LA <br /> 5 aL.� � oa <br /> iIESS <br /> PRORATION <br /> I;LUS <br /> P,FNALTY <br /> OTHER <br /> NJ <br /> ,I <br /> OTHER <br /> +t <br /> Received by Date Receipt No. Permit No. I suance DatL& Mailed Delivered <br /> 4 APPLICANT—RETURN.ALL-COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 ' <br />