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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 is here made c on b i ess i t 'urisdictional area of the Sa aqui ocal Health Di t$" <br /> F Business (DBA) Address <br /> i a Owner c Address / <br /> Z Firm Partners, Address nd Telephone Numbers F <br /> CL <br /> Business Telephone N Contractor Licence No �- <br /> Emergency Telephone No.— �1 <br /> � , <br /> L Applicants Name (Print) C 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) 1 <br /> Serial No. ( CAL. License No. CAL. License Renewal No. <br /> 1 , <br /> I 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 w <br /> 4. ❑ SANITATION PERMI _ O <br /> Job Addre4o tion �OwA g <br /> ner I?�o�l�e Address <br /> 15'SEPTIC TANK ❑ CESSPOOL C-[EACHING FIELD KSEEPAGE PIT ❑ PACKAGE PLANT <br /> Q-PERMANENT ❑ TEMPORARY )EINEW ®"REPAIR C1 OTHER -� <br /> S. 11 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction ) Disposal Site_ Qom ` <br /> No. of Units f <br /> Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 _ <br /> l Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity ; No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ^f <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft- <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared this a <br /> pati and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a e an regulat' s the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY /z/2y/tea <br /> - - Fee 15 Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received6' <br /> _ , Y January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> _ - DATE DATE REMITTED AMOUNT DUE CHECKED <br /> t AMOUNT <br /> FEE , �0 <br /> LESS <br /> PRORATION + ` <br /> PLUS <br /> PENALTY <br /> OTHER ? <br /> OTHER <br /> Received by Date Receipt No. -Permit No, 7 ssuan a Date ailed <br /> Delivered <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br />