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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION -4 <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> 0 ENVIRONMENTAL HEALTH PERMIT SEPTAGE -A <br /> LIQUID WASTE LN <br /> Application is her y madet car on business in the jurisdictional area of the Sa J a in Lec tri t� <br /> FBusiness Name (DBA) Address � L �`7 <br /> a Owner Address <br /> J Firm Partners, Addresses and Tele hone Numbers— Glt <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> - <br /> L Applicants Name (Print) 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. Ucc^se 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 /> ❑ SANITATION PERMIT <br /> Job Address/Location -►� <br /> Owner �� 1 VOc .e6 Address / <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD r❑,.SEEPAGE PIT ❑ PACKAGE PLANT , <br /> ❑ PERMANENT 11 TEMPORARY 11NEW �q 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, nd sand reg ions of the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE d <br /> LESS <br /> PRORATION p, s .. <br /> PLUS a 1 <br /> PENALTY Ila <br /> OTHER <br /> \ OTHER <br /> OZ�rJ 8' <br /> —7 3-7 137 <br /> ived by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 'LICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> _ 41Q16". 1,0-23« <br />