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t Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.4= 4 <br /> ..6 I APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) �r <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> I , LIQUID WASTE <br /> Applicatio 's he by de to carry n businees in the juriA <br /> s ctjonal area of the an aquin Local Health istrict ( <br /> rn Business Name (DBA) } <br /> r- Address + / <br /> z Owner <br /> a - Address <br /> 3 Firm Partners, Addresses and Tee one ll(u bers <br /> �- a Business Telephone No. 7 C <br /> Emergency Telephone No. n71 <br /> F -1 Contractor Licence No. <br /> k L Applicants Name (Print) Title Date f <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. CAL. License 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 j <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 ocation <br /> Test Date/Time <br /> 4. SANITATION PERMIT✓ ' <br /> Job Address ocation -51' !t <br /> Owner Address , <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD :SEEPGE PITA ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW PKIREPAIR ❑ OTHER <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 <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 /> M <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, an rules and reg lation the Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 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 /> EXPLANATION BILLING REMITTANCE $ REMIT <br /> DAVE DATE REMI 7ATMOUNTDUE CHECKED <br /> r _ AMOUNT , <br /> FEE <br /> EBASE <br /> LESS <br /> PRORAT€ON I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER E <br /> Received by Date �Receipt No. Permit No. - Issua ce Date Mailed Deliv retl <br /> - APPLICANT=RETURN ALL COPIES TO: ENV,RONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,A.O.BON 2009 STOCKTON,CA 95201 <br />