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Applications Will Be Processed.When Submitted Properly Completed. Be Sure 'I 61Vn ft J#P?tion. <br /> APPLICATION T <br /> i (For Non-Transferable, Revocable, and SuspendzbAJY ,JOAQUIN LQ� <br /> ENVIRONMENTAL HEALTH PERMIT HEALTH DISTRICT LSEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Lgcal Health District <br /> ,F Business Name (DBA) <br /> 1— <br /> Address [moi <br /> a Owner Address tr !.c <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. 4 <br /> 1 Contractor Licence No._ 2 ('.Z <br /> L Applicants Name (Print) i <br /> 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 /> 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 0 <br /> No. of Vehicles Stored <br /> 11 <br /> No. of Chemical Toilets Stored fT <br /> 3. ❑ PERCOLATION TEST 1 <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 A <br /> Owner C Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑.PACKAGE PLANT r? <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 CID <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 /> 3 <br /> Plant Capacity No. Units Served i <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 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County r <br /> ordinances, state laws, and rules and regulations of the Sag Joaquin Local Health District. r <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: [1ANNUALLY ❑-PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ _ REMIT <br /> BASE EXPLANATION DATEAMOUNT OUE CHECKED <br /> DAT REMITTED AMOUNT <br /> FEE <br /> r <br /> LESS <br /> PRORATION r <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> M C 1Y 1 �� <br /> Received by Date Receipt No. Permtt No. ISxr;7m Date Mailed- Delivered <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES, 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> I <br />