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h Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.- <br /> APPLICATION " <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry n busineAj in the j ri dictional area of the San Joaquin Local Health District <br /> cn <br /> Business Name (DBA) Address <br /> a Owner L__ ALT 1i A I I Address <br /> LA <br /> J Firm Partners, Addresses an Telephone Num ers <br /> aBusiness Telephone No. <br /> i — Emergency Telephone No. <br /> ' -j Contractor-Licence No. <br /> L APplicanfs Name,(Prinf)! <br /> Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information _ <br /> 1;'.,.0-PUMPER 'EHICI:E'PERfY ITREGISTRATION (FOR-.EACH VEHICLE) <br /> For July 1, _ 4 June 30, 18 K Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL: Lic se Renewal No. <br /> I p Y <br /> Ca acit Gal_Weight's&_Measures'Nb. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> -No. of Vehicies Stored <br /> -- <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. 4 <br /> Test Location Test Date/Timex _ Y <br /> 4. ❑ SANITATION PE�tIU _ a.. <br /> Job Address/ ocatio y (, <br /> Owner Address T - <br /> ❑ SEPTIC TANK ❑ CESSPOOLLEACHWG.FIELD -SEEP7GE PIT ❑ PACKAGE PLANT <br /> ❑ ,PERMANENT ❑ TEMPORARY NEW ") ` f <br /> .REPAIR ❑ OTHER <br /> 5. ,❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> k Type Construction f Disposal Site t - <br /> No:of Units Equipment Storage/Cleaning Location(s) x <br /> A -0 PACKAGE TREATMENT PLANT ForJuly 1, -June 34, 19 ------ - <br /> -'Opbrator Name -� Where Certified <br /> Plant Location <br /> 4 _ <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 /> 4 <br /> a <br /> c x•- <br /> 1 hereby certify have prepared his plicati and that the work will be done in accordance with San Joaquin County s <br /> e lwsf S <br /> ordinances, stata , rule and ul 'on off t e an J -quin al Health District. <br /> .APPLICANT'S SIGNATURE <br /> _ w t <br /> •• FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNITi w # <br /> ❑ PER SITE ❑ EACH ,....a. ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 1 <br /> Y BASE EXPLANATION -'BILLING 'f REMITTANCE $ REMIT. <br /> DATE r+ DAT REMITTED AMOUNT DUE CHECKED <br /> t FEE - y AMOUNT P <br /> LESS <br /> - .CA Al <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> } <br /> Received by Date Receipt Nod Permit No <br /> i <br /> - APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERv10ES. Issu nce to Mailed Delivered ;. <br /> r 1601 E.HAZELTON AYE., .0.Boy 2009 STOCKTON,CA 95201 <br />