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Applications Will Be Processed When Submitted Properly, ompleted.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on�uslnessl nn the jurisdictional area of the an Joaquin Local Health District <br /> UrBusiness Name (DBA)L-E_E ( 1 Address Sc3 ,2 C-LA"v�C <br /> aOwner Address <br /> J Firm Partners, Addresses i(r>dTelephone Numbers <br /> 0. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. r <br /> Applicants Name (Print) t--E-E Title Date ' <br /> Please check Applicable Category(1-7)and Fill In the Required Information t <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. 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 Location Test Date/Time <br /> 4. ❑ SANITATION PE IT <br /> Job Add is/Lo tion �a' <br /> c <br /> Owner Address11 <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ZNEW 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 cer Y have prepared this applicatiol and that the work will be done in accordance with San Joaquin County <br /> V ordinances,state lawl, a rul sandregul ion of oaq 'n Local Health District. <br /> APPLICANT'S SIGNATURE <br /> j <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> MFNT�� <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE C <br /> DATE DATE REMITTED AFEE <br /> LESS A <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ' OTHER <br /> Received by date Receipt No. Permit No. Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />