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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 /> Application s here mrry o hsl In the jurisdictional area of the S Joa n Local ealth trict <br /> to Business Na 8A) 9l �ac � � Address © r [� <br /> I- r �; <br /> z Owner r f F Address l <br /> Firm Partners, Addresses and Telephone Numbers f 7 <br /> CL Business Telephone No. 3 '3- --13 Emergency Telephone No. /20'*- <br /> Contractor.Licence No. 2 <br /> Applicants Name (Print) E Title Date_ j6- <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (F.OR-EACH'VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <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. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PER <br /> MI <br /> Job AddreLo atio 7 a r ' <br /> r <br /> Owner Address <br /> 9-SEPTIC TANK ❑ CESSPOOL ErLEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 9-TJEW ❑ REPAIR ❑ OTHER {�) ` <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 191 <br /> Type Construction Disposal Site r <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 1 <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. - E <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> fi ordinances, state laws, an a nd regula ' s th an Joaquin Local Health district. <br /> I` APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> 4 <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE r REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 4 LA� <br /> LESS. .. <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - - "">. _• _ <br /> Received by Date Receipt No Permit No. I Is ce ate Mailed Delivered — <br /> - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES , 1601 E.HAZELTON AVE.,P.O.Box 2009 sSTOCKTON,CA 95201 <br />