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ApplicationsWill 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 /> Applicatio ' her y made to r n business in the jurisdictional area of the San Joaquin Local 'St t <br /> N Business Name (DBA) 7 - lb r/ <br /> a Owner Address <br /> "`Address <br /> J Firm Partners, ddresses an Telephone N rs <br /> Business Telephone No. Emergency Telephone No. <br />` Contractor Licence No. <br /> a <br /> L Applicants Name (Print) Title _ 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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location est Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner ddress <br /> SEPTIC A CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ' REPAIR ❑ OTHER <br /> 5. ❑ 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 <br /> Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 S <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. �y <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 reg a 'ons of the San Jo Ruin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &R ived By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTAN E $ REMIT <br /> DATE D T REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �" �`0 f <br /> LESS <br /> PRORATION ,R1 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date <br /> Receipt No. Permit No. I s nce ate Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZEL NAVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />