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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> v (For Non-Transferable, Revocable, and Suspendable) <br /> 1 ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> I <br /> A licatio h pp y madejto a on sines 'n the j dictional area of the San Joaquin LocakHeal '�i-ic <br /> I N Business Name (DBA) ddress <br /> aOwner Address <br /> F <br /> Firm Partners, Addresses and Telephone Numbers <br /> !ij <br /> CL <br /> Business Telephone No, f Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) .. Title Date <br /> I Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> f For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No, CAL. License Renewal-No. <br /> ECapacity Gal., Weights &Measures No. ` <br /> Equipment Parking.Address ) <br /> 2. ❑ PUMPER YARD �} <br /> For July 1, June 30, 19 O <br /> 4, No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST _ <br /> I R.S. or R.C.E. Namur- ", R.S. or R.0-.E. No. <br /> Test Location 4 Test Date/Time <br /> 4: ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Ownerj Address <br /> 11 SEPTIC TANK CESSPOOL L LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 1:1 PERMANENT ❑ TEMPORARY 11 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) <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. j <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I 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 an"d reguI t' ns of the San Joaqu' Local Health District. k <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jury 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EX�.LANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS !/ ' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 1 <br /> OTHER <br /> i <br /> Received by Date Receipt Nv. Permit No. Is uan a Date Mailed ed <br /> APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,.P.O.Box 2009 STOCKTON,CA 95201 ' <br /> t <br />