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.. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �,.� � <br /> APPLICATION <br /> (Por Non-Transferable, Revocable, and Suspendable) <br /> // ENVIRONMENTAL HEALTH PERMIT SEPTAGE ^- <br /> �jWy�sc LIQUID WASTE <br /> Application i ereby ode to car on usine in th jurisdictional area of the San Joaquin c I Heat Di trict <br /> Business Name (DBA) Address <br /> i Owner Address <br /> a <br /> Firm Partne , Addresses and Telephone Numbers <br /> a Business Telephone No. ��� �___� Emergency Telephone No. <br /> a <br /> f -j Contractor Licence No. <br /> Applicants Name (Print) G Q Title �'i� Date a~ � <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, 19 Disposal Sites 4 <br /> Description(Make/Yr., Color) <br /> i <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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R_S. dr R_C.E. No. <br /> Test Location Test Date/Time <br /> 4QXSANITATION PERMIT 'VA. ' <br /> 4 Job Addres Location <br /> Owner X Address i <br /> 11SEPTIC TANK 11CESSPOOL ty LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE ANT r S <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW RET PAI ❑ 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) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name 1 ` Where Certified <br /> Plant Location <br /> I Plant Capacity i 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 /> � t <br /> I hereby certify that I.have repared this-application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a I and re ations of the JO Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Fee IS Due: ❑ ANNUALLY _ ❑ PER UNIT ❑ PER SITE 1 ❑ 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 /> (� r AMOUNT <br /> CFEE � ! ic.r <br /> k LESS <br /> PRORATION y <br /> PLUS tl. <br /> PENALTY <br /> OTHER <br /> rr <br /> OTHER <br /> eReceived by f Date, Receipt No. Permit No. Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 9520 <br />