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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 Suspendabie) SEPTAGi ... �. <br /> ENVIRONMENTAL HEALTH PERMIT ''� <br /> LIQUID WASTE <br /> i Applicatio hereby mato car on busines in the jurisdictional area of th an J quin ocal Health Dist t <br /> F Business Name (DBA) Address Ec �0 52. 2l <br /> z Owner Address <br /> 52 Firm Partners,Addresses and Teie-p1}op Num s <br /> r <br /> CL Business Telephone No. �Lff(� Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date _ <br /> Please check Applicable Category(1-7)and Fill In the Required Information. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) S` <br /> For July-1, June 30, 19 —Disposal Sites <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'S <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. r <br /> Test cation Test Date/Time <br /> 4. SANITATION PERMIJ„ <br /> Job Address Ca. <br /> tipn �,�l <br /> Owner � Address <br /> JOSEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE P(ANT I <br /> ❑ PERMANENT 11TEMPORARY El NEW - � - -- REPAIR- ❑ OTHEp > } <br /> 5. ❑ CHEMICAL TOILETS For-'July i, -Junef 3019 <br /> Type Construction Disposal Site. <br /> No. of Units .. : 'Equipment Storage/Cleaning 1:6,eation-(s) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1'~ 1 e 4♦ <br /> .y� <br /> Operator Namt Where'Certified <br /> Plant Location a t ,zl r n <br /> Plant Capacity No-Units Served 1----° ��J t <br /> 7. ❑ LAUNDRY For'.July 1fi-:June 30 19 <br /> , e <br /> SIZE: ❑ Less Than 1,000 Sq- Ft.,�10 More.Than 1,060 Sq, Ft- # � <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby ce�r`tify that I'hAve'prepared this application and that the work +will be dorre-in accordance with San Joaquin County <br /> ordinances, state laws, a d rules and re lations of SV.J a uin Local Health District. <br /> APPLICANT'S SIGNATURE XIN <br /> 1 <br /> '--FOR DEPARTMENT USE ONLYJi <br /> `% <br /> Fee Is Due: El ANNUALLY ElPER UNIT 13PER SITE I Cl EACH ❑ January 1 &Receivdd By January 31 ❑ July 1 &Received By July 31 <br /> `BILL'ING »RE TANCE $ � REMIT <br /> BASE EXPLANATION <br /> AMOUNTDUE CHECKED <br /> f, ATEy REMITTED AMOUNT <br /> FEE I j <br /> LESS _ <br /> PRORATION <br /> PLUS NU <br /> S <br /> PENALTY <br /> OTHER <br /> OTHER <br /> dg ( -;?- <br /> Received by Date Receipt No. Permit No. F lrWance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2D09 STOCKTON,CA 95201 <br />