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Applications Will Be'Processed When Submitted Properly Completed. Be Sure To Sign The Application.- 3 <br /> APPLICATION <br /> L � t <br /> >'— (For Nan-Transferable, Revocable, and Suspendable) <br /> 70�. ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> 1-P LIQUID WASTE <br /> Application is h by made to carryon busingi 1 the jurisdictional area of an Joaquin Local_Health District <br /> Business Name MBA) - <.Al �� Address - � Is k <br /> zOwner Address , <br /> Firm Partners, Addresses andI p one Nu ers <br /> a. Business Telephone No. ," �� Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print, Title r Date <br /> Please check Applicable Category (1-7) and FIII 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 /> Serio! No. GAL: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 _ x ° <br /> ' No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name - ... R.S. or R.C.E. No. <br /> Test Lo ation Test Date/Time <br /> 4. ANITATION PER Mz _ <br /> Job Address/Location s�� <br /> Owner Address <br /> TV'SEPTIC TANK © CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW — —.J'kt FiEPAIFi ❑ OTHER ► {' <br /> 5. CHEMICAL TOILETS For July 1,-June 30, 19 1 �� <br /> Typ Construction Disposal Siteet. __ ___ ! }t � F•- <br /> No. f Units -Equipment Storage/Cleaning Location(s)---- <br /> 6. ff`PACKAGE TREATMENT PLANT-for July 1, -June 30, 19 <br /> Operator Name — Where Certified <br /> Plant Location �*+ <br /> Plant Capacity No.'Llnits Served <br /> 7. ❑ LAUNDRY For July 1, -June 30,19 ,. <br /> SIZE. C3 Less Than 1,000 Sq. FL,' ❑ More Than 1,000 Sq. Ft. - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ` <br /> r <br /> I hereby certify that I have prepardd.this app_li 'on and thaCthe work w`_ill be done in-accordance with San_ Joaquin County <br /> ordinances, state laws, and rules a ' ulat' ns the an Joa uin-L cal Health District. u <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY` ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ Januar;`1 &Received ay-January 31 ❑ July 1 &Received By July 31 <br /> 'f"'..:.. REMIT <br /> BILLING REMITTANCE '�$ <br /> BASE EXPLANATIONN' " AMOUNT DUE CHECKED <br /> .,DATE DATE REMITTED <br /> - - - AMOUNT <br /> LESS i; "r, of <br /> PRORATION _ <br /> PLUS -- <br /> PENALTY <br /> OTHER_- W <br /> OTHER ti.•° yt . <br /> Received bye Date Receipt No. Permit No. Issuance Date Mailed } Delivered <br /> •tPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES '1601 E.HAZELTON AVE.,P.O:Box 2009 'STOCKTON,CA 95201 _ - <br />