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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 /> ENVIRONMENTAL <br /> d <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) 45I!!"::0 W" Mffk Address IP 7 4, 7 4001" <br /> a Ow <br /> z / d 1��, Address R0 6AX '767 eL o I�/ <br /> Owner <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. go <br /> S D Emergency Telephone No. <br /> Contractor Licence No. x7– <br /> L Applicants Name (Print) e s T Title —. 1® Date r �� — <br /> Please check Applicable Category (1-7) and Fill in the Required Information t <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. v <br /> V �. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address 1 <br /> 2. ❑ PUMPER YARD )-N <br /> For July 1, ' June 30, 19 l <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3, 0 PERCOLATION TEST F <br /> R.S. or R.C.E. Name t R.S. or R.C.E. No. <br /> Test Location l– sr '� Test Date/Time <br /> 4. ❑ SANITATION PERMIT �w'l�� <br /> Job Address/Location {'� <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ FESSPOOL ❑ LEACHING FIELD _ PEEPAGE PIT 7°0"PACKAGE PLANT <br /> D PERMANENT ❑ TEMPORARY ElNEW1 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction + tDisposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> _ i <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 a regulations of the Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> REMIT _ <br /> - BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> t AMOUNT <br /> FEE _ �--` �o• ��...x� <br /> LESS }} r <br /> PRORATION ! <br /> PLUS `I <br /> PENALTY <br /> OTHER <br /> OTHER F <br /> Received by Date - 1 Receipt No. Per No Issuance Date Mailed DeIliveretl G, <br /> APPLICANT_RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.a 2009 STOCKTON,CA 95201 <br />