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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> - � APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> A i5p I i catjQR is hereby rrjaCp to caon business in the jurisdictional area of the Sa aquilnjoca 'ealth Distri t P r <br /> H Busines N me (DB ) 0 t y dreams <br /> z Owner Address l7� <br /> Firm Partners, Addresses an phone urtjJaers r 1 <br /> a Business Telephone No.. r Emergency Telephone No. - <br /> Contractor Licence No. i <br /> L Applicants Name (Print) Title Date ! �� <br /> Please check Applicable Category (1-7)and Fill in the Required Informalion l i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) E <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. Liccn&e Renewal No. <br /> - I <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 W <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location I Test Date/Time ";,1 <br /> 4. F SANITATION PERMIT �7 .� <br /> Job Add /Location 37 g 5 ` a� ` _!` <br /> Owners �4ee«lam Address �s� <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> orPERMANENT ❑ TEMPORARY NEW F REPAIR ❑ OTHER i <br /> TOILETS For Jul 1 -June 30 19 <br /> 5. CHEMICAL TO y <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 <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 <br /> I hereby certify that I hav repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws n les(knd regula ' ns of a San Joaquin Local Health District. <br /> 11 1 <br /> APPLICANT'S SIGNATURE <br /> Z2 W A0I <br /> FOR DEPARTMENT US NLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH .0 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> EASE EXPLANATION BILLING REMITTANCE $ AMOUNT_DUE CHECKED , <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS l <br /> PRORATION „ <br /> 1 <br /> PLUS (� <br /> PENALTY - <br /> OTHER <br /> OTHER e <br /> x <br /> -1 / i h-0 <br /> Received by -— - Date - Receipt No. _ ,,,,,, ermit No. YssuancefDate- Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Boz 2009 <br /> APPLICANT--RETURN ALL COPIES TO: _ENVIRONMENTAL HEALTH PERMIT/SERVICES . STOCKTON,CA 85201 <br />