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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 /> Application is hereW made to carry on business in the jurisdictional area of the San Joaquin Local Health Dis rict <br /> wBusiness Name (DBA) Address ot,, <br /> i Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 2 4 Emergency Telephone No. <br /> Contractor Licence No. Z• � <br /> Applicants Name (Print) `-�T�� S.,&Lr, Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information ,' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) pU <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 TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. BISANITATION PERMIT <br /> Job Address/Location Z21(o N, ALmooe Lod• —_aT�zp' <br /> Owner � Z Address ,00 e�'m,!° ?G C/��L<J.t1 . Wk!.� �I �,70-y <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 19-SEEPAGE PIT ❑ PACKAGE PLANT <br /> M-15ERMANENT ❑ TEMPORARY ❑ 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 laws,q4ruies and gulations the 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 &9 Ye, By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITT CE <br /> BASE EXPLANATION DATE DAT RE TED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 414- '[' y"s <br /> LESS — <br /> PRORATION <br /> PLUS <br /> PENALTY / <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,C 95201 ' <br />