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ApplicationsWIIP Be Processed When Submitted Properly Completed. Be Sure�,q Sign The Application. <br /> APPLICATION ` s -` <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applic tion is hereby , det _ r o busi es the favi dictional area of the San oaquin Local Health District <br /> y Business Name (DBA) 'Address <br /> aOwner��, � �� Address <br /> 1 Firm Partners, Addresses and a epho �r)uerc Business Telephone No. `. _ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title — <br /> Please check Applicable Category (1-7) and Fill in the Required Information . ate <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <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 Gal., Weights & Measures No. t <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.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PE"I <br /> Job Address/Location <br /> Owner <br /> Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY IEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site I <br /> No. of Units <br /> Equipment Storage/Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified 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. <br /> I hereby certify th I have prepare this applicati n and that the work will be done in accordance with San Joaquin County <br /> ordinances, stat laws, nd rules and Iregul io sof Ye S T Jo uin Local Health District. <br /> APPLICANT'S SIGNATUR <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> EFEEIL �q <br /> p <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> li� <br /> Received by - Dat Receipt No. permit No- ssu ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITSERVICES 1601 E.14AZELTOR AVE.,P.O.Box 2009 STOCKTON,rA� 1 <br />