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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> j-C (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> ApplicationI ere car Jyy ma o cry on Inesss th risdictional area of the SaP7JJoaqu ocal Health Distri <br /> yBusiness N e DBA_)--�; + 7� �-sus= Address //'� + G <br /> z Owner Adress Ire <br /> Firm Partners, Addresses and Telephone Numbers Ill <br /> aBusiness Telephone No. ,v� �' K Emergency Telephone No. ' <br /> Contractor Licence No. <br /> LApplicants Name (Print) s EX Title C?G Aye 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 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 PERMIT- <br /> Job Addres / ocation <br /> Owner Address *7d4 A) <br /> B'SEPTIC TANK ❑ CESSPOOL © LEACHING FIELD 3—SEEPAGE PIT ❑ PACKAGE PLANT ` <br /> (?'PERMANENT ❑ TEMPORARY ©'NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 N <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) PI <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 accordant( San Joaquin County <br /> ordinances, state laws, and rul d regulatio th an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> ;F <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑'J ary r ceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTA s $ <br /> BASE EXPLANATION � A OUNT DUE CHECKED <br /> DATE DATE - REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION t <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> 7 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HE LTH PERMIT/SERVICES 1601 E.HAZELTbN AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />