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r 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 /> Applicatio h by de to car on busi ess in the' rlsdictional area of th Jo <br /> ,*Local Health Di riot <br /> Business Name (DBA) �f � . AddressS®� <br /> a Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers !I <br /> IL <br /> Business Telephone No. 0 Emergency Telephone No. n <br /> Contractor Licence No. <br /> Applicants Name (Print} c) Title ' Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites ) <br /> Description(Make/Yr., Color) <br /> Serial No. CAL.. License No. CAL. License Renewal No. f <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 Location Test Date/Time <br /> 4. I%SANITATION PERMIT c <br /> Job Address/Location <br /> ® r�'- <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELDSEEPAGE PIT 0PACKAGE PLANT Cj <br /> 11 PERMANENT 11 TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site i <br /> No. of Units Equipment Storage/Cleaning Locations) <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 r les and reg lations a San O quin Local Health District. <br /> APPLICANT'S SIGNATURE X ' <br /> 4 <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 I <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> f AMOUNT # <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY _- <br /> OTHER G <br /> OTHER Cl <br /> D 5`f3 � <br /> Received by Date Receipt No. Permit No. Is uance qatB Mailed Deff ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST CKTON,CA 95201 <br />