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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application isApereby made to carry on business in the jurisdictional area of the San Joaqui ocal Health District <br /> y Business Name (DBA) .1. f=dt!t l2 Address � <br /> aOwner-i�r F�LL�� Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 7, <br /> _ <br /> �Applicants Name (Print) CY Title u r+4w(� Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information r '� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites (�Ci <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 s <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 PERMIT <br /> Job Address/Location G _ <br /> O.wr Address 71%C <br /> �SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ 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) <br /> 6. ❑ PACKAGE.TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name' Where Certified <br /> Plant.L-ocation <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 /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state.laws, and rules and regul ion f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT-ISE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH- ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION B E FtE1UtITp,T ENCE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEEy' S <br /> . . - r <br /> LESS <br /> PRORATION- <br /> PLUS /U <br /> PENALTY / <br /> OTHER <br /> OTHER - -- - - <br /> r' i <br /> o \6 <br /> Received by Date Receipt No. Permit No Isl Date Mailed Delivered 3 9 <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />