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Applications Will 8e 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 /> Applicatio reby e to Carry on•f'usiness�in the jurisdictional area of the San Joaquin Local Hea�D'st 'ct <br /> y Business ame (DBAt Add re s_ " � <br /> _ <br /> zOwner Address , P �_ <br /> J Firm Partners, Addresses and Tele hone Numbers <br /> OL Business Telephone No. a Emergency Telephone No. <br /> Contractor Licence No, e✓r. + ;` <br /> L Applicants Name <br /> (Print) ,. �� Title Date <br /> i Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1.`-0!PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July-1 ' -'-June 3'0,'1'6 Disposal Sites —� <br /> Description•(Make/Yr;,-Color) -. -Z4. ' <br /> Serial No. ',- I CAL. License No. _CAL'--License Renewal No. <br /> Capacity Gal., Weights & Measures No. W <br /> Equipment Parking Address Z f i <br /> 2. ❑ PUMPER YARD .% I <br /> For July 1, June 30, 19 '4 { <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored k t <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name H.S. or R.C.E. No. <br /> Test Location Test Date/Time t F <br /> 4. SANITATION PERMIT <br /> Cli J r j <br /> IN <br /> Job Addres ocati � � � � t i <br /> Owner _�_- , isu _ Address <br /> ❑ SEPTIC TANK ❑ CESSPOOE PrLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE-PLANT <br /> PERMANENT ❑ TEMPORARY 17 NEW XREPAIR OTHER1it <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 f t <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,t ❑[More Than 1,000 Sq. Ft. + <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Ma. <br /> 3 <br /> { <br /> 1 <br /> 1 hereby Certify that I h prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state I s, lesjand regul ions of t�Sn�Joa <br /> quin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 1c� FOR DEPARTMENT USE ONLY <br /> Fee Is Due: I-] ANNUALLY El PER UNIT 0 PER SITE ❑ EACH ❑ January'1 &Received By January 31 July 1 &Received By July 31 <br /> . BASE I EXPLANAT.iOAr' REMIT BILLING REMITTANCE $ AMOUNT-DUE CHECKED <br /> "DATE DATE REMITTED - AMOUNT <br /> FEE qI-S, <br /> LESS <br /> PRORATION <br /> PLUS W <br /> PENALTY ,{ •'`�' <br /> OTHER -� - <br /> OTHER <br /> Received by. J UalpReceipt No.. Permit No. 1 suance Date Mailed _ Deliv d <br /> e <br /> APPLICANT—RETURN ALL COPIE6'TO: ENVIRONMENTAL HEA. .PERMITlSERVICES 1601 E=HAZELTON AYE-,P.O.Box 2009 STOCKTON,CA 95201 <br />