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r F Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.- <br /> „d APPLICATION <br /> a (Far Nan-Translerable, Revocable, and Suspendable) 4� <br /> ' ENVIRONMENTAL.HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> s Appficatio .s here m to carry o usine in the jurisdictional area of th quin�cal �Ith 1st �et. <br /> y Business Name (DBA) Address i <br /> i Owner <br /> c Address <br /> Firm Partners, Addresses and Tel phone Nuffmbers <br /> CL <br /> Business Telephone No. (o b Emergency Telephone'No. <br /> Contractor Licence No. 3 <br /> L Applicants Name (Print) �E . [ Title <br /> 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 /> I Ca acit <br /> p Y Gal., Weights 8 Measures No. � <br /> Equipment Parking Address ' <br /> a <br /> 2. ❑ PUMPER YARD M. <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 cation Test date/Time <br /> 4. SANITATION PERMIT I <br /> L �-- <br /> Job Add ss/Locati <br /> Owner - dresses t <br /> ❑ SEPTIC TAN ❑ SSPOOLLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY -❑ NEyy REPAIR 0 OTHER f <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June.30. 19 <br /> Type Construction Disposal Site <br /> No. of Units717 <br /> . Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 , <br /> Aerator Name <br /> Plant Location Where Certified � <br /> .� <br /> Plant Capacity No. Units Served r <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 accorda a with San Joaquin County <br /> ordinances, state laws, and rul and regulatio of th a Joaq i Local Health Di rict. <br /> APPLICANT'S SIGNATUREX r ~ <br /> FOR DEPARTMENT U O,,r{NLL <br /> Fee Is Due: 11 ANNUALLY, ❑ PER UNIT ❑ PER SITE , ❑ EACH ❑ nL�r 1 &Received R Januar 31 Y <br /> Y Y ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION .BILLING MITT- E - $ REMIT <br /> DATE DA REMITTED AMOUNT DUE CHECKED <br /> r AMOUNT f <br /> FEE <br /> E <br /> LSS <br /> t <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ? � g <br /> Received by Date Receipt Ala= - Permit No - 1 suan a Date ailDeiiveretl JAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTpN AVE.,P.O. 2009 STOCKTON,CA 95201 <br />