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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. .q „ <br /> tF ! APPLICATION . <br /> �L (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE ,, <br />' LIQUID WASTE <br /> Application i ereby made carry on business in the jurisdictional area of the San Joaqui Local Health Distric <br /> m Business Name (D _ Address ® _ <br /> z Owner <br /> a Address -+-��.�,� <br /> Firm Partners, Addresses and Telephone Numbers <br /> Q.f a Business Telephone No. /G Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Int mation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) � <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights,S 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 L anon Test Date/Time <br /> 4. SANITATION PERMIT <br /> ,J,o��b��Addres Locativ_n <br /> 0er y' Address <br /> L1 SEPTIC TANK ❑ CESSPOOL VPACHING FIELD SEEPAGE PIT 0 PACKAGE PLANT R� <br /> ❑ PERMANENT ❑ TEMPORARY L�1'NEW ❑ REPAIR ❑ OTHER `}J <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 /> `6 <br /> i <br /> A <br /> I hereby certify that I have prepared this application and that the work will be done in a ca ance with San Joaquin County <br /> ordinances, state laws, and rules and r 7lations of the an Jo in Local Health Distr,(c�! <br /> APPLICANT'S SIGNATURE X (!` <br /> FOR DEPARTMENT US� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J ry 1 &Received By January 31 ❑ July i &Received By July 31 <br /> BASE EXPLANATION BILLING RE TT CE $ REMIT <br /> DATE RFWTTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> OTHER t <br /> OTHER k <br /> Received by Date Receipt No. Permit No - s at Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001, .HAZELTON AVE.,P.O.Box 2009, STOCKTO ,CA 95201 <br />