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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 a <br /> Application is her by made•to carry on usiness in the jurisdictional area of the San Joaquin Local Health District <br /> / <br /> H Business Name (DBA) 12d511 Address_ <br /> zOwner . <br /> a ��� Address <br /> Firm Partners, Addresses and Telephone Numbers _/ <br /> aBusiness Telephone No. ——_ II I Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) 4=0�,r_ ✓ �/ Title �R �- Date — <br /> ( Please check Applicable Category (1-7) and Fill in the Required 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. License 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 r '� <br /> 3. ❑ PERCOLATION TEST - <br /> R.S. or R,C.E, Name _ R.S.or R.G.E.'_No. <br /> Test Location Test Date/Time ' <br /> ❑ SANITATION PERMIT <br /> :lob Address/Location - elo. i�4-a;_ '- <br /> •Owner ��1L;��. Address ` <br /> ElSEPTIC TANK ❑ CESSPOOL EACHING FIELD ,❑�SSE--EPAGE PIT Q PACKAGE�PLANT C� <br /> ❑ PERMANENT ❑ TEMPORARY 13 ,-,,NEW REPAIR OTHER: . - <br /> 5. ❑ CHEMICAL TOILETS For July 1 i June 30, 19 <br /> Type Construction Disposal Site <br /> No. of UnitsEquipment Stora elCleanin Locatio s <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,19 <br /> rv.. �. u' <br /> Operator Name-" ��,ra-.v 4` Where'Certified <br /> Plant Location ` <br /> Plant Capacity I No. Units Served <br /> 7. ❑ LAUNDRY For JUiy 1, -June 30, 19 <br /> SIZE: © Less Than 1,000 Sq. Ft., ❑ More Than 1,000"5q. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t - `,� <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 regulatio s of the San Joaquin Local Health,District. <br /> APPLICANT'S SIGNATURE X — '` ` <br /> f 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 -❑ July t &Received By July 31 <br /> REMIT <br /> r BLANATION BILLING REMITTANCE <br /> ASE EXPAMOUNT DUE CHECKED <br /> I DATE DATE REMITTED AMOUNT <br /> e - <br /> FEE i <br /> LESSs <br /> PRORATION j <br /> PENALTY r - <br /> OTHER . r_yv6 <br /> l <br /> Y <br /> „ OTHER I - <br /> o <br /> Received-by Y Date ,k - Receipt No. - Permit No. '- IssLfance D e Mailed Delivered <br /> APPLICANT—RETURN ALL"COPIES TO: -"_ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON�AVE.,P.O-Box 2009 STOCKTON,CA 915201 "Y <br />