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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 /> Ji ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> j LIQUID WASTE <br /> Applicatl s hereby made on busines the jurisdictional area of tqpSan Joaqui Local Heallm Districi4,�... <br /> Business Name (DBA) AddressN, <br /> P. <br /> Owner y Address <br /> J Firm Partners, Addresses and �1e ho a Number <br /> 0.IL Business Telephone No. (� - Emergency Telephone No. <br /> aContractor Licence No. <br /> Applicants Name (Print) Title - Date <br /> Please check Applicable Category.(1-7)and Fill in the Required Information <br /> 1. © PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> P <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 & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD _ <br /> -For July 1, June 30, 19 <br /> No. of Vehicles Stored y <br /> No. of Chemical Toilets Stored ; <br /> 3. ❑ PERCOLATION TEST _ <br /> R.S. or R.C.E. Name t # R.S.or R.C.E. No. <br /> t Test cation a Test Date/Time <br /> 4. SANITATION PERMIT <br /> reoc & ' .Job Add <br /> 1 <br /> OwnerAddress Lkulz) ' <br /> ❑ SEPTIC TANK ❑ CESSP,OOL---XLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 3 ^j <br /> PERMANENT ❑ TEMPORARY ❑ NEW . REPAIR ❑ OTHER f C> <br /> 5. ❑ CHEMICAL TOILETS tFor July 1, -June 30, 19 101, I- <br /> �� <br /> �Type Construction � � � �= �Disposal Site ` <br /> ��...��'L. � <br /> Nii�of�Cfnii's # R �" s 1 Equipment Storage/Cleaning Location(s) <br /> b3�❑ PACK AGETREATMEMT PLANT For July 1,4 June 30, 19 ° <br /> f <br /> Operator Name y ) e , ,� ` 1 V4lhere Certified <br /> Plant Location ) " <br /> Plant Capacity ( € No..6nits Served -� <br /> 7. ❑ LAUNDRY For July.1_bune 30, 19 <br /> SIZE! ❑ Less Than 1,000 Sq: Ft., ❑ Mor�1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> t I hereby certify that i have prepared this ap ication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rui u ions a San Joaquin Local Health District. 1 <br /> 'APPLICANT'S SIGNATURE X I <br /> PFOR DEPARTME104T USE ONLY - t r 4 r v I <br /> Fee IS Due: ❑ ANNUALLY 11 PER UNIT ❑'+;PER SITE,p �]EACH ❑ January 1 &F} Ceived By January'31 >`Q July,t Received By July 31 <br /> .z _ ' REMIT <br /> 'BILLING REMITTANCE $ <br /> _ BASE AMOUNir DUE CHECKED <br /> J ! 7E�XP� <br /> DATE DATE _ REMITTED — 4,,,..a✓- ,•* AMOUNT <br /> FEE <br /> LESS <br /> PRORATIONPLUS <br /> PENALTY <br /> OTHER <br /> E <br /> OTHER _ <br /> 'k Received by Date '� f fieceip'No: 1 S # �p rmit No. - ^+v i Iss ante D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 4 11601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA X952 <br />