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Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheApplication. <br /> APPLICATION t <br /> (For Non-Transferable, Revocable,and Suspendable) ' <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati is ereby e t on b ness its the jurisdictional area of the San Joaqui ocal al D' t <br /> v;Business m ( ) vsAAddr /�aS <br /> aOwner_ Address <br /> J Firm Partne , Addresses and Telephone N m ers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. on If <br /> Ll� c Q <br /> L Applicants Name (Print) Title Dat <br /> Please check Applicable Category (1-7)and Fill lithe 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 /> + <br /> No. of Chemical Toilets Stored � <br /> 3. ❑ PERCOLATION TEST `p <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L cation Test Date/Time <br /> 4. SANITATION PERMIT i <br /> Job Address/Location �solf <br /> Owner Address a <br /> ❑ SEPTIC TANK ❑ CESS OOL LEACHING FIELD g SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site l <br /> No. of Units Equipment Storage/Cleaning Location(s) i <br /> 6. El 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. Fl. <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 and regul 'ons f aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1 &Received By January 31 0 July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECK <br /> PATE DATE REMITTED <br /> AM <br /> FEE q's <br /> LESS t <br /> PRORATION w <br /> PLUS 17 <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER <br /> Received by Date Receipt No. Permit No. fissuancd pate Mailed Delivered <br /> APPLICANT—RETURN <br /> � <br /> NTT—RETURN/A� COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O_Box 2009 STOCKTON,CA 95201 <br />