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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> # APPLICATION <br /> Y (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE. <br /> LIQUID WASTE <br /> Applicati hereby made tocaarry on usiriess in th uris nal area of the S�J,oaa in Local Health D' riot <br /> wBusiness Name (--A) C Addresses �� <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses an Tele hone Numbe <br /> IL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required In ormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, 1 ,lune 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> -Serial No. CAL. License No. CAL. Licc ase Renewal No. <br /> Capacity Gal., Weights &Measures.No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> F No. of Vehicles Stored <br /> I[ 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 La6 ion - Test Date/Time <br /> k 9 py/ <br /> 4. 9SANITATION PERMIT <br /> Job Address/ cation <br /> Oer F Address r �� <br /> El SEPTIC TANe ❑ CESSPOOL �FACHING FIELD PACKAGE PLANT <br /> ❑ PERMANENT E] TEMPORARY L� 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 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. <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 rules and re tions of the Sa oa uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> f Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Ja2 Wry ,9 1 Received 8y July 31 <br /> BILLING REMITTANCE REMIT <br /> i BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE 4ET AMOUNT <br /> FEE <br /> LESS i <br /> PRORATION <br /> PLUS <br /> I PENALTY <br /> OTHER <br /> t' <br /> OTHER <br /> F <br /> Received by -- Date Receipt No.� Permit No. - Issua ce Date Mailed Delivered I - <br /> ` APPLICANT=RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O..Boz 2002 STOCKTON,CA 95201 <br />