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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. r <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application re y mad t car on business in the jurisdictional area of the San Jo uin Local H Ith Dist /� <br /> Business Name A) Address �. ! <br /> aOwner Address <br /> Firm Partners, Address4andlTel ne N mbe Faa Business Telephone No � Emergency Telephone No. <br /> Contractor Licence No.L Applicants Name (PrintTitle Date <br /> Please check Applicabl -7) and Fill in t e Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �. <br /> For July 1, June 30, 19 Disposal Sites <br /> i <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License 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 -�^--- ---._..e---- "" <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. orfR.GE. No. <br /> Test ocation Test'Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Lo ation <br /> r <br /> OwnerAddress �� <br /> ❑ SEPTIC TANK 01CES OOL �101LE HING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAN <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR OTHER s yy,� l�kl�yr3 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r" l <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> I <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 /> w <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County -. <br /> -} <br /> ordinances, state laws, a leg a reg Iation the an Joaquin L cal Health District. i <br /> APPLICANT'S SIGNATURE X I <br /> FOR DEPARTMENT USE ONLY i <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received ByJanuary 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED. <br /> " <br /> AMOUNT '] <br /> FEE' <br /> LESS 9 <br /> tiYPRORATION Y � � ,r.. <br /> PLUS _. - <br /> PENALTY .. <br /> OTHER <br /> OTHERyY ix _ - -- <br /> Received by Date Receipt No, Permit No. „ Is uance ate arced Delivered ' <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRO ENTAL HEALTH PERMITlSERYICES P -_1"�1BDi E.HAZELTON AVE., .eon 2009 STOCKTON;CA95201 <br />