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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) 0 <br /> ENVIRONMENTAL_.HEALTH PERMIT SEPTAGE <br /> = A1010 WASTE <br /> Application is hereby made to-carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> I <br /> Business Name (DBA) A S S 0 AJ Address <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. A 9 7/ Emergency Telephone No. <br /> Contractor Licence No. g3 _ <br /> LApplicants Name (Print) /we Title tate <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br />( 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) U7 <br /> For July 1, June 30, 19 Disposal Sites 7C� <br /> Description (Make/Yr., Calor) <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> i 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. f <br /> Test Location Test Date/Time <br /> t 4. U SANITATION PERMIT <br /> Job Address/Location 6 57z��fc <br /> Owner Address S,4- 76 <br /> SEPTIC TANK ❑ CESSPOOL J4 LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY .4 NEW ❑ REPAIR ❑ OTHER f- <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ti <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 ifR <br /> Plant Location p <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 a <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1 <br /> APPLICANT'S SIGNATURE X <br /> Z7 8p <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE i <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ReceivedLby Date Receipt No. - Permit No Issuancetuate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 r/i <br />