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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) C9 <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE G <br /> LIQUID WASTE <br /> Applicati Qn, isher y made carry onAusiness in the jurisdictional area of th San Jo quin Local Health District s <br /> w Business Name (DBA) U A 4".- Stq � t.0-4"'S Address ,�o l- �l <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and T lephhonne Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. cZ 3 <br /> J PP (Print) / 1�inF/S Title ,S% Date <br /> Applicants Name Print .ter <br /> Please check Applicable Category (1-7)and Fill 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 /> 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 <br /> No. of Chemical Toilets Stored 1�1 <br /> 3. ❑ PERCOLATION TEST O'Q <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. CJ <br /> Test Location _ Test Date/Time 0 <br /> 4. 9 SANITATION PERMIT �1 <br /> Job Address/Location e, d0 S - <br /> Owner y —Wj? Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 20 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW PC REPAIR ❑ OTHER <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and <br /> �-reggulations f the San Joaquin Local Health District. <br /> APPLICANT'S SIG URE <br /> E' ZJ <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br />