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f 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 /> Application i ereby made to ar on iness in the jurisctional area of the San aquin Local Health District <br /> rn Business Name (DB Address <br /> 747 <br /> z Owner— <br /> a '-� Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. leo Emergency Telephone No. <br /> Contractor Licence No. i <br /> els <br /> Applicants Name (Print) Title <br /> Date 1✓ <br /> Please check Applicable Category(1-7)and Fill in the Requ�adlnformatlon <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. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> I For July 1, June 30, 19 <br /> No. of Vehicles Stored t <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.ZR. Name R.S. or R.G.E. No. <br /> TesTest Date/Time <br /> JATION PERMIT <br />, Job Address/Location <br /> Owner ddress <br /> r <br /> El <br /> 18f TANK 11 CESSPOOL ❑ LEACHING FIELD ❑ PACKAGE PLANT <br /> If PERMANENT ❑ TEMPORARY ❑ NEW Ry <br /> REPAIR ❑ OTHER 6 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 (� <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 r <br /> Plant Location <br /> Plant Capacity <br /> No. Units Served (7' <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 herebycertify that l V <br /> Y have prepared this application and that the work will be done in accordance with San Joaquin Cou y <br /> ordinances, state laws, and nd re u ions e S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> w <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 f Jul 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br />►NS DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE qS <br /> LESS <br /> PRORATION <br /> PLUS``.. <br /> y, PENALTY <br /> �+ OTHER <br /> 'OTHER <br /> 1693 <br /> Received by Date F,f, - Receipt No. Permit No. Is te Mailed Delivered <br /> APPLICANT—RETURN ALL-COPIES TO: ENVIRONMENTAL HEALTH PEgMIT/SERVICES 1601 E.I.AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �� <br />