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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE 1 ,� <br /> J <br /> Application ' ereby made o carry on b siness in the juris 'ctional area of the Sa Joaquin Local Health Distri ; <br /> wBusiness Name BA) L Address �tO- 24—" 7 <br /> z Owner Address - � - <br /> 1 Firm Partners, Addresses and Telephone Nu ers i <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable+Category (1-7) and Fill in the Requi d Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, 'm <br /> June 30,19 Disposal Sites <br /> Description(Make/Yr., Color) i <br /> Serial No. CAS_. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 1 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored y <br /> 3. ❑ PERCOLATION TEST I �t <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. r; <br /> Test L cation Test Test Date/Time �l <br /> 4. SANITATION PERMIT <br /> Job Add s/Location Z <br /> Owne <br /> d `Address { r <br /> LR'SEPTIC TANK ❑ CESSPOOL �ACHING FIELD,t 2SEEPA6fE. PIT ❑ PACKAGE PLANT <br /> 12"PERMANENT ❑ TEMPORARY NEW S LJ REPAIR iN ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,-19 3 ° <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning'Location(s) <br /> $.1,❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19.1 {{{ <br /> Operator Name - Where Certified <br /> Plant Location <br /> Plant.Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 t <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 in accordance with San Joaquin County <br /> 1 <br /> ordinances, state laws, and s and regulations o S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X } <br /> I <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 /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION 5 <br /> /E6X.�, ^ DATE DATE REMITTED AMOUNT i <br /> i FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> i <br /> e <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed 0elivered [ <br /> APPLICANT—RETURN ALL COPIES/: ENVIRON�ENTA HEALTH'PERMIT/SERVICES 01I.E.HHA�ZEELJTON AVE.,P.O.Box <br /> 2009 STOCKTON,CA 95201 - <br /> t 7/I <br />