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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 /> y ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> " LIQUID WASTE <br /> Applicati is hereb mad o car n business in the jurisdictional area of the San Joaquin Local Health Di s rict <br /> FBusiness Name (DBA) �/ n s - `c �� Address <br /> a Owner C6 ry 8?,4., �r, e 6 W e- Address <br /> J Firm Partners, Addresses and Telephone Numb rs S3 J 6/,' /ate_ 044 AJ�-Le <br /> CL <br /> Business Telephone No. - J�� Emergency Telephone No. `c <br /> j. Contractor Licence No. <br /> Applicants Name (Print) Title (Jr_ C -c •.__ Date 0 —a "'e4) <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 /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. GAL. Liccrise Renewal 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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner ( _lt} Address1, <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ,�7 REPAIR ❑ OTHER t <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 N F <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <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 /> a <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County j <br /> ordinances, state laws, and rules and regulati ns oft an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> V� <br /> G <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jufy 31 <br /> I <br /> REMIT <br /> BASE <br /> E BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 'DATE DATE REMITTED - AMOUNT <br /> Ll r- <br /> 1 FEE V3 Q C� <br /> �_ <br /> LESS <br /> PRORATION ' <br /> PLUS , <br /> PENALTY <br /> I OTHER <br /> OTHER <br /> OR3 (al <br /> Received by Date l Receipt No.- Permit No. I uance Date sled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVFCES- 1601 E.HAZELTON AVE.,P:O.-Boii 2009 STOCKTON,CA 95201 <br />