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Applications'Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> " ``�•' 1� (For Non-Transferable, Revocable, and Suspendable) + <br /> a` ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application ' hereby mide to carry o usiness in jurisdictional area AtheSaaquincal Health Distri t <br /> Business N BA) ddre <br /> ? Owner Address <br /> a <br /> Firm Partners, Addresses and/Telephone Numbers " <br /> aBusiness Telephone No. �3 Emergency Telephone No. <br /> Contractor Licence No. a 7� <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. 11 <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> �f <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 - <br /> I No. of Vehicles Stored t <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST Oil If t <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. f <br /> E Test Location i Test Date/Time <br /> f 4. SANITATION PERMIT_ i <br />! D <br /> Joh Addressiiocation <br /> Owner Address - <br /> r U-SEPTIC TANK ❑ CESSPO 13-LEACHING FIELD e SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY Q-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 (Rd <br /> Operator Name' Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. C1� <br /> r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prep Is applic I n and hat the work will be done in accordance with San Joaquin County �T <br /> ordinances, state laws, and a ^regulatio a Joaquin Local Health District. <br /> 5 APPLICANT'S SIGNATURE X <br /> 7 Al <br /> 'I <br /> FOR DEPARTMENT USE ONLY <br /> E� <br /> 'Fee IS Dile: ❑ ANNUALLY PER UNIT PER SITE ❑ EACH January 1 R Received By January 31 July 1 &Received By July 31 <br /> - _ REMIT ! <br /> BILLING REMITTANCE AMOUNT DUE CHECKED 1 <br /> BASE EXPLANATION DATE DATE REMITTED . <br /> AMOUNT <br /> FEE <br /> LESS h' <br /> PRORATION <br /> k PLUS <br /> PENALTY - ! <br /> OTHER ` <br /> OTHER <br /> Received ay Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPpDLI�C#N�Ty—�RETURN ALL COPIES TO: ENVIRgNMEPITAL HEALTH PERMIT/SERVICES -- 1601.E.HAZELT VE„PG.Box 2009 STOCKTON,CA 95�?pl.� 11 - <br /> 0 <br />