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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applica"i <br /> ` APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) � <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the.jurisdictional area of the San Joa uin Local Health District Q <br /> ,�Business Name (DSA) Address /� - <br /> � � <br /> a Owner Address r,r1 <br /> J Firm Partners, Addresses and T lephone Numbers <br /> a Business Telephone No. <br /> a _1P Emergency Telephone No. <br /> Contractor Licence No. <br /> I <br /> Applicants Name (Print) = c — Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Li-�cise Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 1 <br /> 2. ❑ PUMPER YARD _i t <br /> For July 1, June 30, 19" <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. 13 PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. f y <br /> Test Location Test Date/Time W <br /> 4. A SANITATION PERM T <br /> Job Address/Location y t <br /> Owner o6O 13 MEiiig 7W 'I Address r <br /> ❑ SEPTIC TANK ❑ CESSPOOL CM LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -Jeune 30, 19 <br /> Type Construction d Disposal Site { <br /> No. of Units Equipment Storage/Cleaning Location(s) 5 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> =1 <br /> Plant Capacity l l No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ,I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f <br /> I� <br /> 1 hereby certify that I have prepai- d this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, anoules-a�O regul to s of a San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH { <br /> ❑ January 1 $Received By January 31 El JUN 1 8 Received By July 31 <br /> -� REMITTANCE $ REMIT <br /> BASE EXPLANATION BILLING A <br /> GATE DATE REMITTED AMOUNT RUE CHECKED <br /> ru` j �}/''` AMOUNT <br /> LESS <br /> FEE 1� ! 6 J� <br /> PRONATION <br /> PLUS k t <br /> PENALTY <br /> k <br /> OTHER _ <br /> OTHER <br /> V <br /> 9_10 sW L I n �7 l lol Iq <br /> Received by Date Receipt No. Permit No. Issuance Uale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STO�CKTON,CA 95201 j <br />