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Applications Will BeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br />{ (For Non-Transferable, Revocable, and Suspendabie) <br /> i ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl icatj is ereby m e to c rry on siness iQ the jurisdictional area of the San Joaquin L al Health stri t <br /> ca BusineW(DB ) Addres �vsa Owner Address <br /> J <br /> Firm Partners, Addresses and T epho a Numbers <br /> CL <br /> Business Telephone No. 6�� _ Emergency Telephone No. 7 <br /> Contractor Licence No. ��✓� 8J , <br /> LApplicants Name (Print) �!f TitleDate <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> ormation <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. <br /> CAL. License Rerewal 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 cation Test Date/Tjme N <br /> 4. SANITATION PERMIT IW <br /> Job Addre s/Locatio "� <br /> Owner Address a J <br /> 11 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE LANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW i REPAIR WOTHER s <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 a <br /> Type Construction Disposal Site a <br /> No. of Units Equipment Storage/Cleaning Location(s) t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1 <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 <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 ules and re ulati 'ns of the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X w <br /> 3 <br /> FOR D A MENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 i <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNTI]UE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ; a' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Oate Receipt No. Permit No. � Itsuande Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> f <br />