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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 's her by ade to carry n business in the juris ictional area of th an J quin Local Health-0, rict S <br /> Business Name (DBA) _! <br /> Address U <br /> a Owner 11 <br /> Address <br /> J Firm Partners, Addresses and Tele o e Numbers <br /> Ch <br /> 0. Business Telephone No, Emergency Telephone No. Q <br /> Contractor Licence No. <br /> Applicants Name (Print) Title pate 7 f <br /> Please check Applicable Category (1-7)and Fill in the Required Information . :. <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> R. <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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. gSANiTATION PERMIT <br /> Job Addre /Location <br /> 0 ner Address <br /> CE <br /> SEPTIC TANK ❑ SSPOO LEACHING FIELD El PIT 11 PACKAGE PLANT ` <br /> PERMANENT ❑ TEMPORARY NEW 1:1REPAIR ❑ OTHER <br /> 9❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction - 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 <br /> Plant Location <br /> Plant Capacity No, Units Served A <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 g ations o San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ' <br /> FOR DEPARTMENT USE ONLY <br /> c <br /> Fee IS Due: 13 ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT 1 <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE I <br /> LESS <br /> PRORATION <br /> PLUS \ FQ <br /> PENALTY' <br /> OTHER <br /> OTHER <br /> s <br /> Received by - Date Receipt No. Permit No. Issuance Date MailedDeli//v red # <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAZELTON AVE.,P.O.Boll 2009 STOCKTON,CA 95 r <br /> s � 9 <br />