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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 Suspendable) <br /> E ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is here y made to carry on business in the jurisdictional area of the/,n�oaaquin Local Health District <br /> ,F Business Name (DBA)_ � .d��PP�/S�iL r'��p,taS Address/- �� <br /> aOwnerAddress <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0.a Buhone No. <br /> siness Tele i <br /> p �P Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) 41e Tide Date S__—3-27-- a <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1: ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) , <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 <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 Lo( In Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location <br /> Owner Gt5.Y 5 C Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD � SEEPAGE PIT ❑ PACKAGE PLANT O� <br /> 0'PERMANENT 11 TEMPORARY El ,NEW tS REPAIR '❑ OTHER <br /> S.. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 C. <br /> Type Construction Disposal Site 0 <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> q 1 <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 rules and gala ' of th an oaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY ) <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jvly 1A Received By Juiy 31 <br /> BILLING REMITTANCE 5 REMIT <br /> BASE EXPLANATION AMOUNT DUE CHEGKED <br /> I DATE DATE REMITTED AMOUNT <br /> EEE ys� <br /> LESS <br /> PRORATION <br /> :} r <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Is - Received by Date Receipt No. Permit No. I uance ate-,.' Mailed De rve <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />