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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) SEPTAUE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ' her y mad on Ines in a jurisdictional area of the S oaqui ocal e Ith Dist <br /> r Business ddress <br /> z Owner s� A d ess dtaxil <br /> Ja I� ' <br /> Firm Partners, Addresses and T le hone4�Numbers <br /> a. Business Telephone No. —� 1 :7� Emergency Telephone No. � <br /> Contractor Licence No. <br /> Applicants Name (Print) Title ' Date `.A3 <br /> Please check Applicable Category(1-7)and Fill in the Required Information i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites LA <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 PERMIT % Zgwt ®J <br /> Job Addres / ocati n <br /> Oiw er Address ®m ,�. <br /> L� SEPTIC TANK ❑ CESSPOOL �CEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT � r <br /> PERMANENT ❑ TEMPORARY 9—flEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �11 <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 /> I/f <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 hav ep ed this p c ion d that the work will be done in accordance withquin County <br /> ordinances, state laws, d ru a reg o San Joaquin Local Health District. �Z�ri <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januar 1 & d By J uary 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE EMITTED AMOUNT DUE CHECKED <br /> tAMOUNT <br /> FEE Aq� e O .(/3-0 43 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Maile Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />