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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) F <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i by made t carry on sin in a jun ctional area of the Sa oaqui ocal Health pis <br /> rn Business Name (D ) +` Address <br /> 4 Owner dress <br /> I 2 Firm Partners, Addresses and T le hone Numbers ► <br /> 4 Business Telephone No. .� Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name Name(Print) Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Info atin <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <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 L ation Tes Dat Time 1 <br /> SANITATION PER�III T <br /> J SJ� <br /> JobAddress/ o ation <br /> OAddressRr 1 <br /> SEPTIC TA ❑ CESSPOOL L 'CHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY Lg'NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> s. <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 /> h <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, a es and reg lati ns of e J quin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januar 1 &Received B Januar 31 <br /> Y Y Y ❑ 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 0 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> j7�� <br /> I <br /> Received by -- .Date Receipt No. o <br /> Permit No; I ance b4te, j Mailed Delivered <br /> c APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O.Box 2009 STOCKTON,CA 95201 <br />