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ApplicationsWill Be Processed When Submitted Properly Completed-''Be Sure To Sign The Application. <br /> APPLICATION <br /> c (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE oaquin Local Health District <br /> Application is here made toarry�n btysiness in the jurisdictional area of th San J <br /> F Business Name{DBA) s <br /> z Owner Address / <br /> jdc Address <br /> Firm Partners, Addresses and'Telephone Numbers <br /> CL Business Telephone No. �^ <br /> J Contractor Licence No. Emergency Telephone No. <br /> L Applicants Name (Print) <br /> o Title �S/ Date� <br /> Please check Applicable Cate !!]- <br /> 9 ry (1-7) and Fill In the Required Information <br /> t 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) so <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License Na <br /> Capacity CAL. License Renewal No. <br /> Gal., Weights & Measures No. I. <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 <br /> Test Location <br /> R.S. or R.C.E. No. <br /> 4. 0 SANITATION PERMIT Test Date/Time <br /> Job Address/Location a <br /> Owner �~ Address ted! <br /> ❑ SEPTIC TANK ❑ CESSPOOL 1 LEACHING FIELD ❑ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW SEEPAGEPIT ❑ PACKAGEPLANT k <br /> REPAIR ❑ OTHER O <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 f, -June 30, 19 <br /> Operator Name <br /> Plant Location Where Certified d <br /> Plant Capacity No. Units Served S <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 /> r <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 and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ## <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACHf <br /> ❑ January-1 &Received By January 31 El July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE ' $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE i G =vr AMOUNT= <br /> LESS <br /> PRORATION s <br /> PLUS <br /> PENALTY , <br /> OTHER <br /> OTHER <br /> i <br /> Received by Date' <br /> Receipt No. Permit No. Issuan Date <br /> APPLICANT—RETURN ALL COPES Tq:- ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed el <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA 9 <br />