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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 /> 4 <br /> ` ENVIRONMENTAL HEALTH PERMIT SEPTAGE J <br /> LIQUID WASTE <br /> Application her by ade to car on bu 'Hess in tnhe j�ur�isdictional area of the an Joaquin Local Health District <br /> Business Name (DBA) i f -+�^�� Address es° 13 <br /> aOwner Address — <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. (v Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) J. 1e)l D Title CS Date - j <br /> Please check Applicable Category (1-7) fid Fill In the Required Information F <br /> 1. 11 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 S <br /> 2. ❑ PUMPER YARD 0 <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 L cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/ ocation 6C3 <br /> Owner Address 0 <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ,SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ 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 /> I <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, a rules and gula s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE XIV <br /> ` <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ uary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING ITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> os � 3Ll 03 Cn <br /> Received by - Date - Receipt No. Permit No 1 suance Qate 'Mailed Delivered <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16o1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 M <br />