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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 4 APPLICATION <br /> rr (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is h reby de to carry on+bu iness in the jurisdictional area of the San Joaquin Local Health District <br /> F'Business Name (DBA) + Address 7X <br /> i Owner Address <br /> I J Firm Partners, Addresses and Te ephone Numbers <br /> aBusiness Telephone No. �.I i q&07 Emergency Telephone No. <br /> 1 Contractor Licence No. 2 <br /> L Applicants Name (Print) Title Date d <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) d <br /> For July 1, June 30, 19 - Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. Liccrise Renewat No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address . <br /> 4 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 PEIT <br /> + Jab Address/L cation15 , t <br /> Owner Motif 40noceA, Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 1 ❑ LEACHING FIELD <br /> SEEPAGE PIT El PACKAGE PLANT a^. <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 /> I 6. ❑ PACKAGE TREATMENT PLANT 'For July 1, -June 30, 19 <br /> i Operator Name Where Certified {� <br /> Plant Location 5 <br /> Plant Capacity No. Units Served <br /> L 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 r les and regu I <br /> ations n <br /> San Jo uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 4-- U 4 8 4611 <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION - AMOUNT DUE CHECKED <br /> DATE DATE REMITT <br /> AMOUNT <br /> FEE <br /> kLESS 1� <br /> r PRORATIONPLUS <br /> L L <br /> PENALTY lir <br /> OTHER J(- J� <br /> OTHER O <br /> I Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered , <br /> - APPLICANT--RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERM ITYSERVICES 16011 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 F <br />