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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ' (For Non-Transferable, Revocable, and Suspendable) } <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> r' Applicati n i her made to carryfo mess in�th��risdictional area of eS Joaquin L al Healt D strict <br /> H Business Name (DBA) �. � Is �� -_ nY. Address <br /> �— - I <br /> z Owner Address <br /> Firm Partners, Addresses and elephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title IY1QIr Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information 1 <br />` 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O� <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Uccnse Renewal No. i <br /> Capacity - Gal:, Weights & Measures No. } <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored r <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ;5 SANITATION PERMIT <br /> Job Address/Location a J <br /> Owner Lk�-o4-,3"� 21M�t?L2 Address +No <br /> ❑ SEPTIC TANK ❑ CESSPOOL .❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> . PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR AW,OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 4- <br /> Type Construction Disposal Site <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 /> Plant Location <br /> Plant Capacity - No. Units Served r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 . - %, <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. X <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coutity _ <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT-(ISE-ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ JWY 1 &Received By July 31 <br /> tt REMIT <br /> BILLING 4 REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> lbw <br /> LESS r �/ <br /> PRORATION — <br /> PLUS <br /> PENALTY <br /> OTHER e ' <br /> OTHER <br /> 15-81 6^ � <br /> Received by -Date �. Receipt No., Permit No. Issuance Date ailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON A .O.Box 2009 STOCKTON,CA 95201 <br />