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Y 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 i hereby made to carry on business in the jurisdictional area of the San Joaquin ocal Health District <br /> UBusiness N me BA) B Addre <br /> z Owner Address <br /> a - <br /> L) Firm Partners, Addresses and Tel.i one Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> a <br /> 1 Contractor Licence No. <br /> �Applicants Name (Print) �1�. P/��� Title . -' Date <br /> Please check Applicable Cate goryk(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) T <br /> I Serial No. �� CAL. License No. CAL. Licznse Renewal No. <br /> Capacity iM Gal.,Weights & Measures No. <br /> ' Equipment Parking Address �M <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored iM <br /> No. of Chemical Toilets Stored I� <br /> 3. ❑ PERCOLATION TEST <br /> ' R.S. or R.C.E. Name N R.S. or R.C.E. No. <br /> Test Location iN. Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> (v el J �e_�py ESe .VL e,-v eG <br /> Job Address/Location - <br /> Owner NI- Address <br /> 09 SEPTIC TANK CESSPOOL ❑ LEACHING FIELD ® SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 <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 Where Certified <br /> Plant Location <br /> Plant Capacity �M No. Units Served <br /> f 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/Amounl/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 <br /> l, a r d regulations of the S n Joaqui ocal Health District. <br /> APPLICANT'S SIGNATURE X <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 /> I y REMIT <br /> + II BILLING REMITTANCE $ AMOUNTDUECHECKED ' <br /> . RASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> ` FEELESS <br /> 1 PRORATION, I� J - v <br /> PLUS :IM' <br /> PENALTY <br /> ` V <br /> OTHER il! <br /> r OTHER <br /> Received by liate Receipt No, Permit No. Issuance Date fled Delivered ` <br /> h ..APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., ox 2009 STOCKTON,CA,95201 <br />