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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 /> S ENVIRONMENTAL HEALTH PERMIT SEPTAGE . <br /> LIQUID WASTE k(f 68 <br /> Application i reby mad carry business in the jurisdictional area of th,��jjSan aquln Local>le Ith Istrict _ <br /> y Business Name (DBA) Address' 01 X. 5 S <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Tele hone umbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. S <br /> L Applicants Name (Print) <br /> E Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information ri <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites jI } <br /> Description(Make/Yr., Color) V <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 /> t For July 1, June 30, 19 <br /> No. of Vehicles Stored 4� <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. I <br /> Test ocation Test Date/Time <br /> 4. SANITATION PERMIT i <br /> Job Address/ atn <br /> 'O ner Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD XSiEPAGE PIT ❑ PACKAGE PLANT ti <br /> IFE PERMANENT_ ❑ TEMPORARY NEW 11REPAIR ❑ OTHER 1 <br /> 5, 11CHEMICAL TOILETS For July 1,-June 30;;19 <br /> Type Construction Disposal Site <br /> j <br /> No. of Units Equipment Storage/Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �1 <br /> Operator Name Where Certified ��TT <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 accord an� wIt'San Joaquin County <br /> ! ordinances, state laws,an ules�ratjons, e SaMJ -Local Health District. �l 1 <br /> APPLICANT'S SIGNATURE X J/ <br /> f V <br /> k <br /> FOR DEPARTMENT USE OLY <br /> I Fee Is Due: 11 ANNUALLY ❑ PER UNIT El PER SITE 11 EACH ElJanua 1 eived By January 31 ❑ July 1 &deceived By July 31 >i <br /> BILLING REMIT7ANC $ REMIT <br /> EASE EXPLANATION DATE DA E "REMITTED AMOUNT DUE_ CHECKED <br /> 4 <br /> RMOUNT <br /> Y <br /> FEE <br /> I <br /> LESS <br /> PRORATION _ <br /> PLUS ° <br /> PENALTY <br /> OTHER <br /> I OTHER - <br /> f Received by Date Receipt No. Permit No. Issuance Date Ma ed Delivered <br /> r r <br /> APALL COPIES TO: � ENVIRONMENTAL H LTH PERMITISERVICE5 � 1601 E.HAZELTON AVE.,P.D. oa'2009� STOCKTON,CA 95201 <br />