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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> k, APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> V ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> IL 1, LIQUID WASTE <br /> Application is ebx made t carry on b smess in the jur� ictional area of the S n Joa uin Local Health Distr' <br /> f i <br /> OF Business Name (DB ) Address <br /> z Owner Address <br /> I <br /> Firm Partners, Addresses and Telephone Numbers <br /> E. Business Telephone No. Emergency Telephone No. <br /> K r <br /> Contractor Licence No. Z 2— <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Require Information I <br /> 1. ❑ PUMPER_ VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) , <br /> For July 1, June 30, 19 Disposal Sites ' <br /> Description(Make/Yr., Calor) <br /> r <br /> Serial No. CAL. License No. CAL. License Renewal No. j <br /> Capacity Gal.,Weights & Measures No. <br /> r <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 /> TesVSrANITATION <br /> ation Test Date/Time ] �4-- 1 <br /> 4. PERMIT- L{= <br /> Job Address/Location 'V'% W <br /> �PERMANENT <br /> AddressTIC TA ❑ CE5 OL ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ TEMPORARY NEW ❑ REPAIR ❑ 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) t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name - Where Certified <br /> Plant Location <br /> Plant Capacity _ ,x No. Units Served <br /> 7. 13 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 /> 1 <br /> i <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances state laws, and rules d regulations of the S n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ..a <br /> Fee Is Due: ❑ ANNUALLY � ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ - AMOUNT DUE CHE ED <br /> DATE DATE REMITTED A NT <br /> FEE 1 <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER J <br /> Received by - Date Receipt No. Permit No. Issuan Datd;, Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />