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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> t <br /> r APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is erebY mad to arry on business illhe jurisdictional area of the S�JoaquinLo��H�alth Distri t <br /> hBusiness Name (DBA �„+ AddressBr <br /> zOwner Q Address <br /> J Firm Partners, Addresses and Telephone Numbers r <br /> aBusiness Telephone No. S'�� -� Emergency Telephone No. 4 <br /> 3 Contractor Licence No. <br /> Applicants Name(Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Require 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. Licc.se Renewal 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 /> i <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test�Lo tion Test Date/Time <br /> 4. ANITATION PERMIT <br /> Job AddressJL anon <br /> Owner Address w <br /> ❑ SEPTIC TANK AD CESS OOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PA KAGE PLANT "e] <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �3 <br /> Type Construction <br /> 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 �V <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 11 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEANING, Chemicals Used/AmounVMo. <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 and re ulat' s oft an oaqum Local Health District. ; <br /> j <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY j <br /> Fee Is Due: ❑ 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 /> FEE <br /> LESS UOf <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br />{` 1��►�s r��r91�1 �� 1 <br /> E Received by Date Receipt No. Isitiairice Date Mailed Delivered <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />