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s, Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION ~ <br /> (For Non-Transferable, Revocable,and Suspendable) 1 <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE y <br /> 1 <br /> Applicatiorl,is hereby m4or o siness' thejurisdictional area of the S o quin Lo I Healt istrict <br /> w Business (DBA)_4( )1(0 r, o Addre s '007'^ I <br /> a Owner 4 S Address , <br /> r 4 <br /> Z.Firm Partners, Addresses and Tel hone Numbers <br /> 14 Business Telephone N� Q�� �' l �3 _._ Emergency Telephone No. 15/911 g <br /> Contractor Licence No. 3�0_�S57?a /- <br /> L Applicants Name (Print.) ..-Title bate <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> I 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites k <br /> i Description(Make/Yr., Color) <br /> Serial No. I CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. Y <br /> I Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored o <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 Location Test Date/Time <br /> 4. 1:1 SANITATION PERMIT <br /> Job Address/Location C ' <br /> Owner;27_,M_ OeA.WAS <br /> r t Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL E71EACHING FIELD E$'-S'EEPAGE PIT ❑ PACKA E PLANT <br /> C❑ PERMANENT o TEMPORARY ❑ NEW WEPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 V� <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) f` <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �b <br /> Operator Name Where Certified <br /> I Plant Location j <br /> t Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 11 'More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> M1 <br /> I hereby certify that I have prepared this applicion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an and regulati a an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER-U NIT ❑ 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 /> PATE PATE REMITTED <br /> AMOUNT <br /> FEE CX\� 8 <br /> LESS i I <br /> PRORAT$ON € <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - - <br /> Received by Date Receipt No ermit No. Iss anc Date Mailed - Delivered <br /> APPLICANT—RETURN ALLCOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 952011 - �"' <br />