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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 /> Applica ion is hereby ma e t r o bust es the j ri ictional area of the an Joaquin�Lo°�I He(�Ith District <br /> yBusiness ame (DBA) L o�-Address O `—� <br /> z Owner L I— E U Address <br /> a <br /> Firm Partners, Addresses V T e hone Numbers <br /> IL <br /> Business Telephone No. Emergency Telephone No. m <br /> Contractor Licence No. <br /> L Applicants Nan t Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) - <br /> Serial No. CAL. License No. CAL. License Renewal No. e <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 Ad r ss/Location ^, <br /> ddress <br /> `SEPTIC TANK ❑ CESSPOOL ❑ EACH FI LD ❑ SEEPAGE PIT '0 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR �— `❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 Y i'f /l /lc r ✓ rl� '�!� '`���f��- <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 certif at I have prepared t is application d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules n reg ation Is f e an Jo quin 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 ! b -1-6 q 3 6q 3 l 1- <br /> Received by Datel Receipt No. Permit No. Issua ce Date Mailed Delivered ��� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 52 1 <br />