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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 /> - <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health�Distnc <br /> +n Business Name (DBA) Address <br /> 4 Owner Address <br /> a Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No, <br /> Contractor Licence No. J 6 d- 8 15, <br /> L Applicants Name (Print) Title Dat <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) clt <br /> For July 1, June 30, 19 Disposal Sites Q ] <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 "1 <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. ❑ SANITATION PERMIT _ <br /> Job Address/Location -7, h <br /> Owner Thon!'ys /t`Ie'hL e7-' Address S 7�0 /r�I'Gll�in /3�Qo'1" <br /> M SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> EIPERMANENT ❑ TEMPORARY ® NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) J <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 J . <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 -,rj� <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., El More Than 1,000 Sq. Ft. °S°ry�' )' <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 J in County s <br /> ordinances, state laws-and r es and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X _.— <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 , <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> 1 AMOUNT <br /> 7 �O <br /> FEE � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> l <br /> OTHER <br /> OTHER <br /> Received by pate Receipt No. Permit No. Issuance Hate Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />