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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) `X <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati is her by a etto car�on b ess in the jurisdictional area of the San Joaq Lo Heal District <br /> OF Business Nam (DBA) fi�lf�1 Address /lo`�� r � � <br /> i Owner rC Address <br /> q -- -- <br /> Firm Partners, Addresses an§,WphonaNumbers `` <br /> CL Business Telephone No. .. Emergency Telephone No. <br /> a t <br /> Contractor Licence No. <br /> a �Applicants Name (Print) r N 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 /> �`-'- <br /> Description(Make/Yr., Color)� - <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> I Capacity Gal., Weights & Measures No. <br /> ` Equipment Parking Address <br /> ' 2.= ❑ PUMPER-YARDy t <br /> For July 1, ;lune 30„19 ter• <br /> No. of Vehicles Stored <br /> 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 1 Test Date/Time <br /> �/4.`'❑ SANITATION PERMI <br /> I' !\Job Address/Location �f�3 « ��/\ �•", " '� ' <br /> I O ner � Address <br /> SEPTIC TANK ❑ CESSPOOL , LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT �1 <br /> j PERMANENT ❑ TEMPORARY ❑ NEW 11/6F-PAIR. ❑ OTHER <br /> 5.'`❑ CHEMICAL TOILETS For July 1, -June 30, 19 f 1 <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. � f <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have pared"this application and that the work w ll'he done in accordance with San Jo n County <br /> ordinances, state laws, a u and regulati of the San J quin L2p” I Health District. <br /> S <br /> APPLICANT'S SIGNATURE X <br /> t] <br /> FOR DEPARTMENT USE ONLY <br /> 5 Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH _❑FJanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> a <br /> �- BILLING REMITTANCE ' $ <br /> REMIT <br /> BASE EXPLANATION DATE REMITTED t AMOUNT DUE CHECKED <br /> DATE - <br /> i <br /> i AMOUNT <br /> - FEE <br /> LESS }} <br /> F PRORATION t + I <br /> PLUS a t <br /> PENALTYic ; <br /> OTHER <br /> OTHER <br /> 1W <br /> r - Received b .Dae _ _ Receipt No" Permit No. Issuance Date Mailed Delivered <br /> I ''APPLICANT-RETURN ALL C PIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1661 f.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />