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` Applications Will Be Processed When Submitted-Pr,pp rlycomplefd. Be Sure To Sign The Application. <br /> APPLICATION I <br /> (For Non-Trap feraWt , Revocable, and Suspendable) I <br /> • ` , .. ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br />` LIQUID WASTE <br /> F <br /> Application is hereby made•t c rr on business.irg the juri dictional area of the San Joaquin Local Health District <br /> rA Business Name (DBA) Ur l b AU—dress " 6 <br /> aOwner L Address ._ ,ogj <br /> 1 Firm Partners, Addresses and le hone Numbers <br /> CL Business Telephone o <br /> a TlhNEmergency Tel No.ssr,, <br /> Contractor Licence No. _ T <br /> a Applicants Name (Print) ! ; s <br /> _ Title Date J <br /> Please check Applicable Category (1-7) and Fill in the Required Information ! <br /> 1 ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ° <br /> For July 1,—June-30,-10 Disposal Sites <br /> 1 <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 /> i <br /> 2. E] PUMPER YARD <br /> For July 1, June 30,'19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ` <br /> 3. ❑ PERCOLATION TEST a <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMITZ <br /> Job Address/Location C, <br /> Owner Address [{�: <br /> SEPTIC TANK ❑ CESSPOOL firLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT { <br /> ❑ PERMANENT ❑ TEMPORARY' NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 j <br /> Type Construction Disposal Site I <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> f <br /> fi. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location s <br /> Units Served <br /> 7. 13 LAUNDRY For July 1, -June 30, 19 .. "* r <br /> SIZE; ❑ Less Than 1,000 Sq. Ft., -. ❑ More Than 1,000 Sq. Ft. <br /> Plant Capacity No. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo? p' <br /> 4 f <br /> I hereby certify t I have prepared this application arid that themork will be done in accordance with San Joaquin County <br /> ordinances, st laws, nd rules a regulations f the an�Oaquih Local Health District. <br /> APPLICANT'S SIGNATURE <br /> .FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY .}- ❑ PER UNIT PER.SITEj ❑"EACH ❑ January Rec a edr8 Ja u ❑ Juiy 1 &Received By July 31 <br /> BILLING- REMITTANCE REMIT <br /> BASE EXPLANATION MATE $ MATE I TED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S �! <br /> LESS <br /> PRORATION - <br /> PLUS h <br /> PENALTY h.J <br /> OTHER <br /> OTHER : <br /> Received by Date Receipt No. Permit No. ! uanc Date Mailed Deliveretl o <br /> - APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL�HEALTH PERMITISERVICES 1601 E.HAZELTON AVE 'P.O.Box 2009 STOCKTON, 95 <br /> M <br />