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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is eby made t carry on b iness in the' risdictional area of the an Joaquin Lcotcal Health trlct C <br /> yBusiness Name (DBA) Cl �a ' �- Address �� �Qi <br /> z Owner Address <br /> J Firm Partners, Addresses and Tele hone Noumbers ^f� <br /> IL <br /> Business Telephone No. `�d Emergency Telephone No. <br /> Contractor Licence No. <br /> L A—Applicants Name (Print) (� J #I 6 Title CS Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information p- <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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test ocation Test Date/Time <br /> 4. SANITATION PER IT P <br /> Job Address/ cat-on <br /> Owner Address Jz <br /> ❑ SEPTIC TANK ❑ CESSPOOL I%LEACHING FIELD *SEEPAGEPIT ❑ PACKA E PL NT ^� <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ( ^ <br /> Type Construction Disposal Site V J <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 accordah San Joaquin County <br /> ordinances, state laws, nd rules and r gulation he S J aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> /117 ®S- <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 /> c AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a 1 y1 a <br /> Received by Date Receipt No. Permit No. I uanc Dateailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., oz 2009 STOCKTON,CA 95201 <br />