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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 WASTESs�� <br /> Application i"h ebym de to carry on business in the jurisdictional area of the San Joaquin LOeal Health District <br /> Business N { BA). I Address 12 <br /> z Owner Address L� <br /> Firm P ers, Addresses an�Telephone Numbers �� <br /> Business Telephone No. _ ci� G Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title Date <br /> Please check Applicable egory (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 <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. SANITATION PERMIT <br /> Job Address <br /> 4Q.Cation <br /> Owner S 36 Address <br /> 1<SEPTIC TANK ❑ CESSP60L L ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. [1 CHEMICAL TOILETS For July 1, -June 30, 19 . o� <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 + <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 <br /> r <br /> I hereby certify that I have, repared this application and that the work will be done in accordance with San o uin County <br /> ordinances, state laws, and ule and re lations of the San Joaquin Local Health District. 1 <br /> I <br /> APPLICANT'S SIGNATURE X <br /> P11 'v <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 /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE RE <br /> M <br /> ITTED AMOUNT <br /> FEE 1 a. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Vate Receipt No. Permit No. k Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />