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Applications Will Be Processed When Submitled Properly Completed. Be Sure To Sign The Application ~ <br /> APPLICATION <br /> w (For Non-Transferable, Revocable, and Suspendable) <br /> r <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAsGE <br /> % LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) $&) Address Y <br /> r z Owner <br /> a Address <br /> a Firm Partners, Addresses and Telephone IN <br /> aBusiness Telephone No. 1 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) 4-4 C,O 1 Title Date d i <br /> Please check Applicable Category(1-7)and Fill in the Required Information *^ % <br /> '1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t` <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccrse Renewal No. <br />' Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 e <br /> No. Of Vehicles Stored i <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 Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT I <br /> PERMANENT ❑ TEMPORARY NEW ,� REPAIR OTHER ;5W W e* <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 j <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 /> t ' <br />? SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ) , <br /> r 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 and regulations of the San J :quin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> t - 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 <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE <br /> DATE REMITTED AMOUNT r <br /> FEE wl ,�rf, Q <br /> LESS <br /> PRORATION - 11 <br /> PLUS r <br /> PENALTY J . <br /> OTHER :.. <br /> OTHER ; ' <br /> x� <br /> Received by Date Receipt No. Permi Ne. fssuanc ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: E_NYIRONMENTACHEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P. ox 2009 STOCKTON,CA%201 <br />