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Appli';gtions Will-Bad.Processed When Submitted Properly Completed. Be SureToSign TneAPPucasron. <br /> - ,{t / <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) ( SEPTAGI= <br /> + ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) D. 3� � Address <br /> z Owner Address <br /> 9 <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> CL Emergency Telephone No. <br /> a. Business Telephone No. � <br /> -J Contractor Licence No. <br /> Applicants Name (Print) Titl � Date I <br /> Please check Applicable Category (1-7)and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) (Jt� <br /> For July 1, June 30, 19 Disposal Sitesav` <br /> Description(Make/Yr., Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <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. No. <br /> R.S. or R.C.E. Name <br /> TTest Date/Time <br /> Test Location <br /> 4. SANITATION PERMIT <br /> Job Address/ ovation 4 44*1 <br /> Owner { Address <br /> B-SEPTIC TANK ❑ CESSPOOL a�LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT G1 <br /> PIPERMANENT ❑ TEMPORARY C"NEW ❑ REPAIR 9-0-THER�`�� �s <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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 LA <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. Cl(p17 <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 <br /> ordinances, state laws s and reg ations of t an Jo in cal Health District. <br /> APPLICANT'S SIGNATURE �. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: Cl 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 /> � c <br /> FEE q v <br /> LESS <br /> PRORATION -- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt N. Permit No. ssuanc pat filed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZEL ON AYE., ox 2909 STOCKTON,CA 95201 <br />