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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I� APPLICATION <br /> li i-_�- <br /> !! (For Non-Transferable, Revocable,and Suspendable) <br /> Ei ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is reby made v car on siness in the juris Actional area of the San Joaquin Local Health Distri <br /> wBusiness Name (r-,,., p r Address__ � '7�7 <br /> r` <br /> z Owner Address - �- <br /> a <br /> r 1.;Firm Partners, Addresses and Telephone Numbers <br /> a :Business Telephone No. 'z 04 x��/G S' Emergency Telephone No. <br /> I Contractor Licence No. <br /> Lr Applicants Name (Print) Title Date <br /> p <br /> Please check Applicable Category (1-7)and Fill in the Req red Information L <br /> k1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) L <br /> 'For July 1, June 30, 19 Disposal Sites J) <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 /> t No. of Vehicles Stored <br /> f <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 ate/Time <br /> `4. SANITATION PERM I A'Job Address/Locat' n �. <br /> Owner Address 2 <br /> ❑ SEPTI ANK CESSPOOL URLEACHING FIELDIT ❑ PACKAGE PLANT 'J <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ErREPAIR ❑ OTHER a <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 /> ti. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> t Operator Name Where Certified <br /> Plant Location <br /> :.Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 C <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 0 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ,s <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i <br /> ordinances, state laws, and Zruleand regulations of the San Joaquin Local Health District. <br /> t <br /> APPLICANT'S SIGNATURE X qr.m —CJ <br /> 11 <br /> { r <br /> FOR DEPARTMENT USE ONLY <br /> j Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE t� <br /> LESS <br /> P PRORATION A- C,PLUS <br /> PENALTYOTHER }} <br /> OTHER <br /> J /�ye'}t <br /> ti Received by Date Receipt No. Permit No. Issu ncelate I Mailed Delivered <br /> i <br />' <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,'P.O.Box 2009 STOCKTON,CA 95201. <br /> I J. <br />