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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> -f - (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQIN0 WASTE <br /> Application is -eby made to c rry on busin ss in the ju sdi Tonal area of the San Joaquin Local Health Di t. <br /> Business Name t:e <br /> Ad� ss 7- d' <br /> ��'`I <br /> i Owner Address <br /> J Firm Partners, Addresses and Telephone 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 Information �) <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) lf} <br /> For July 1, `June 30� 19 Disposal Sites <br /> Description(Make/Yr., Color). <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity tf TGal', 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 ''O <br /> R.S. or R.G.E. Name R.S. or R.CTE. No. <br /> Test cation Test Date/Time <br /> 4. El SANITATION PERMIT <br /> Job Address/ cation <br /> Owner -J Address' -Mq4el 47 <br /> ❑ pACKAG PLAN <br /> 1 IC TAN ❑ CESSPOOL LEACHING FIELD {=PAGE PIT <br /> VERMANENT ❑ TEMPORARY ❑ NEW L REPAIR ❑ OTHER I pt7 <br /> 5. ❑ CHEMICAL TOILETS For July , -1June 30, 19 <br /> Type Construction Disposal Site i <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 /> —4— <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. i •• r <br /> - -r <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with nn Joaquin County <br /> ordinances, state laws, and rut 94 regulations Of Zaoaqu in Local Health District. <br /> APPLICANT'S SIGNATURE X '� 1 <br /> FOR DEPARTMENT USE ONLY Ayl <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rece' d January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE MITTED <br /> p AMOUNT <br /> FEE <br /> LESS J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> -___r_ J <br /> OTHER <br /> /a <br /> Received by Date Receipt No. Permit No. 15sua Date {Nailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 160 E.HAZELTON AYE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />