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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio herepy mad to car on sine s i the' isdictional area of the n Joa pin Local Health strict <br /> wBusiness Name (D –� Ad ress 7 `� <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Sf 5' Emergency Telephone No. <br /> Contractor Licence No.dX <br /> Applicants !`Jame (Print) Title — Datey <br /> Please checlk Applicable Category (1-7)and Fill in the RequireAf Information W <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, Liccnse 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 /> 3. ❑ PERCOLATION TEST <br /> F .S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L ation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addre s ocation <br /> Owner Address <br /> 11 SEPT T NK CESSPOOL LEACH G FIELD 09e El PACKAGE PLANT <br /> ❑ PERM N T ❑ TEMPORARY ❑ NEW EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location – <br /> Plant Capacity No. Units Served <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 <br /> ordinances, state laws, and rules and re lations oft Sa uin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING fiCt�ITTANCE $ REMIT <br /> BASE EXPLANATION ATE REWTTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS Cr <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuanc at Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL VE.,P.O.Box 2009 STOCKTON,CA 95201 <br />