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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> pP b APPLICATION ' <br /> �- 1 <br /> (For Non-Transferable, Revocable, and Suspendable) �! <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application.i hereb a to car sine the jurisdictional area of the San Joa i ocal He Ith Di tric <br /> F Business Name B Address <br /> a OwnerAtiAddress r <br /> J Firm Partners, Addresses and Telepho bers NumJ P <br /> i <br /> CL Business Telephone No. L 3. Emergency Telephone No. �1 <br /> Contractor Licence No. �'S <br /> Applicants Name (Print) Title — Date <br /> Please check Applicable Category (t-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:br R.C.E. No. <br /> f � 1 <br /> Test Location Test Datemrrie <br /> 4. ❑ SANITATIONPERMIT " <br /> Job Addres Location S_ `�• <br /> Owner F ' Addresses -" <br /> 91-SEPTIC TANK_ ❑ CESSPOOLf ❑ LEACHING FIELD.'�SEEI AGE PIT: e-0 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY' X NEW '❑'.REPAIR S` ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For JGly'1,-June 30,19 <br /> Type Construction Disposal Sitef <br /> No. of Units 'Equipment Storage/Cleaning-Location(s) { <br /> I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 34, 19-' a <br /> Operator Name , , � �;, Where Certified , <br /> Plant Location <br /> Plaht'Capacity _ No. Units Served <br /> 7. '❑ LAUNDRY For-July 1, -June 30, 19 <br /> Q ! <br /> SIZE' ❑;Less Than.1,000 Sq. Ft., ❑ More�-Than 1,004 Sq. Ft. ) t <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. r i <br /> f <br /> I hereby certify that I have prepared this application and.that the work will be done ir'accordance with San Joaquin County <br /> ordihances,'state laws, and rule5,air�pregulationsl SO oaquin Loc Heap istrict. <br /> APPLICANT'S SIGNATURE XIr OF <br /> FOR DEPART JAbE ONLYFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EAC January 1 &Received By January 37 ❑ July 1 Received By July 31 <br /> 3 <br /> REMIT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED - .k <br /> .r BASE EXPLANATION - DATE DATE REMITTED F <br /> AMOUNT <br /> i <br /> _ S d-0 <br />- FEE `_ . - <br /> LESS <br /> PRORATION' <br /> x PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r �a tS tb <br /> Receive b - Date Receipt No. Permit No. Issuance'Date Mailed Delivered € <br /> I;�! APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />