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Applications Will Bei Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I APPLICATION <br /> ,�. (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> } LIQUID WASTE <br /> Application is beroy made to qgrry on business in the jurisdictional area of th a I Joa uin Local Health District <br /> yBusiness Name-DBA) Address <br /> aOwner � Address <br /> J Firm Partners, Addresses and T le hone Numbers' <br /> aBusiness Telephone No. Emergency Telephone No <br /> Contractor Licence NO. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required nformation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C <br /> For July 1, June 30, 19 Disposal Sites l <br /> Description(Make/Yr., Color) I lllrtrtrt�„111j <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> 1 Capacity Gal., Weights & Measures No. <br /> I Equipment Parking Address I <br /> 2. ❑ PUMPER YARD <br /> For July 1, . June 30, 19 <br /> No. of Vehicles Stored <br /> j 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 L cation Test Date/Time. <br />! 4. SANITATION PE (� <br /> Job Addrs/Lo <br />[ Owner Address <br /> i <br /> El SEPTIC TANK 13 CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ;❑ NEW ❑ REPAIR OTHER V>tAWWJJM <br /> 5. ❑ CHEMICAL TOILETS For July 1,.,-June 30, 19 <br /> Type Construction ;! Disposal Site <br /> No. of Units - Egtuipment Storage/Cleaning Location(s) <br /> 5.' ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name )I Where Certified <br /> Plant Location - _i I _ <br /> b <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 /> - � 1 4 <br /> 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,a les and regulations of San Joaquin Local HealthX.)_ <br /> rict. <br /> APPLICANT'S SIGNATURE X AP <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑'PER--UNIT ❑ PER SITE 1:1 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July.31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE EMITTED AMOUNT <br /> FEE -� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 10, 61 <br /> OTHER - <br /> OTHER <br /> Received by Date r Receipt No, Permit No. - Issuance Date Mailed - Deliver <br /> APPLICANT—RETURN ALL COPIES TO:, ENVIRONMENTAL HEALTH PERMIT/SERVICES -- 1601 E.HAZELTON AVE.,P.O.Box 2009 . STOCKTON;CA 95201 <br />