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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> I �e `( (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT CCC SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) &1?� 19- Sem Address 1P, L9' hoe' <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers -- <br /> aBusiness Telephone No. S�3' �/ '� Emergency Telephone No <br /> _J Contractor Licence No. <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. Liccnse 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.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. R SANITATION PERMIT <br /> Job Address/Location 519/V cr041 mi'/✓ <br /> Owner -3 7'fi0/Iec S —�— Address i9 y9 J eQs-Uf�dj <br /> 11 SEPTIC TANK 1:1 CESSPOOL ❑ LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT W <br /> ❑ PERMANENT ❑ TEMPORARY ❑ 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) O <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 nd regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 6 c / <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> r� AMOUNT <br /> FEE <br /> �l y <br /> LESS r <br /> PRORATION <br /> PLUS IF <br /> PENALTY <br /> OTHER 11 <br /> OTHER <br /> Received by Date Receipt No. Permit No. I suance Qbte Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />