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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> i (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is reby made to carry on busi ess in the jurisdicti al area of the San Joaquin Local Health District O <br /> OF Name BA AO ddress <br /> ay ) i3�- '7e, '7 <br /> Owner Address <br /> J ci DQ <br /> firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> aContractor Licence No. ' Z - <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑'PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> , tiw <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 /> 44No. of Vehicles Stored Y` <br /> No. of Chemical Toilets Stored r <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name � p, f R.S. or R.C.E. No. <br /> Test Location + �'=' i Test Date/Time t <br /> " <br /> 4. 11 SANITATION PERMIT � r <br /> t � <br /> Job Address/Lo ation 2 <br /> Owner � I�� ' � r Address <br /> EPTIC TANK ❑ CESSPOOL 'LEACHING FIELD-- T ❑ PACKAGE PLANT <br /> L'J PERMANENT ❑ TEMPORARY •El,NEW eREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOIL_ET� _S�.FoAly-1,_-June 30, 19 <br /> Type Construction E • '•x Disposal Site ` <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r 4 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity �" No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., El 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 nd regulations of the San 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 Juiy 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER i <br /> -, -7 2 <br /> Received by Date Receipt No. - Permit No. - ss--EL Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.'HAZELTON AVE.,P.D.Box 2009 STOCKTON,00 95 <br />