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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicat'on is her y made to carry on business in the jurisdictional area of the SjAn Joa um Local Health District <br /> -�� Ss� IF �0A'5-AQ Address /'p bf I sp =� sZO/ <br /> Business Name (DBA), � �. - <br /> z Owner ddressdC <br /> _ <br /> j Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. yi�� —7��7 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title� A770 Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> y 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites i <br /> Description(Make/Yr., Color) I <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address p <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 LL tion Test Date/Time <br /> 4. SANITATION PERMIT } <br /> Job Address/Location 3l 575• 1 L_),R- <br /> Owner J:�- Address �� -- <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT k <br /> ©-PERMANENT ❑ TEMPORARY ❑ NEW Q-T�EPAIR ❑ 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 /> I <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19- <br /> SIZE: <br /> 0, 19SIZE: © Less Than 1,000 Sq. Ft., _.. ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 7 <br /> I hereby certify that I ve prepared his applicati and th the�rvork will be done in accordance with San Joaquin County <br /> ordinances, statela -an gulation the Sa oaquirl Local Health District. <br /> APPLICANT'S SIGNATURE <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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEELESS <br /> - 5�y <br /> PRORATION ' + r 6'C i ine. <br /> PLUS <br /> PENALTY fi <br /> OTHER L . 6?jR O <br /> OTHER <br /> E r � 1 ? Ag <br /> Received by Date Receipt No, Pe it No. ISS once DAlb Delivered i <br /> `APPLICANT-RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 -STOCKTON,CA 95201 I <br />