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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 <br /> Application is hereby made to carry on business in the jrisdictional area of the;an Joaquin Local Health District, <br /> Business Name (DBA) -C- Address-° <br /> aOwner �_. �, �•1� t�T� -t_�1_-f Address —S <br /> aFirm Partners, Addresses a T lephone Numbers <br /> a Business Telephone No. --' I Emergency Telephone No. <br /> a i <br /> J Contractor Licence No. �-- <br /> LApplicants Name (Print) IlizA b Title t.' ate <br /> Please check Applicable Category (1-7) and Fill in the Required Information h^ <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) 1 <br /> Serial No, r: CAL- License No.- CAL. Licznse Renewal No. { <br /> 'Capacity - GaLTlNeighfs&Nleasiiires No:" <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD d <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. Name R.S. or R.C.E. No. <br /> Test Location, t ' Test Date/Time <br /> 4. ❑ SANITATION PERMIT ` a <br /> Job Add re s/Location _:S C) y t <br /> ' <br /> s <br /> Owner Address l <br /> ❑ SEPTIC TANK ❑ CESSPOOL` -T�,-L'EACHING FIELDSEEPAGE PIT C3 PACKAGEPLANT—­- f, <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 # <br /> Type Construction Disposal Site 9 <br /> No.`of Units Equipment Storage/Cleaning Location(s) i <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: 11Less Than 1,000 Sq. Ft."---,❑ -More Than 1,000 Sq, Ft. ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.- 1 61 <br /> s <br /> Y i r <br /> I hereby certify that ITh have prepared this appli tion and that the work will be done in accortlance"with San Joaquin County <br /> ,ordinances,';ati�'la , nd rules"a d regulatio sof the S Joaquin Local Health District. <br /> ' eAPPLICANT'S SIGNAT <br /> FOR DEPARTMENT USE ONLY <br /> 11 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ' BILLING REMITTANCE $ s REMIT <br /> ` - 'EXPLANATION AMOUNT DUE CHECKED <br /> BASE^ <br /> - DATE DATE REMITTED AMOUNT <br /> iAV O[ i <br /> FEE <br /> LESS <br /> PRORATION ' - t <br /> PLUS <br /> qPENALTY a. . ��- K.� .�• 44 <br /> OTHER C <br /> s <br /> h _ <br /> _ - <br /> y h- Received.by - Date Receipt No. Permit No.' issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICE$` - 1601 E.HAZELTON AVE.,P.O-Box 2009 . STOCKTON,CA 95201 <br />