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t <br /> v y 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 is hereby made to cara on business in a jurisdictional area of the SW Joaquin Local Health istrict <br /> ,FBusiness Name(PBA) — Address <br /> z Owner Address <br /> 4 - f <br /> Firm Partners, Addresses and Telephone Nu bers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. -- <br /> LApplicants Name (Print) ..P_ Title � Date 51— <br /> ���� <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(MakeiYr.,Color)�_ — <br /> Serial No. CAL. License No. GAL. Lic Ise Renewal No._ <br /> Capacity Gal.,Weights 8 Measures No. --- <br /> 5 <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 LgCation Test Date/Time <br /> 4, SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address s. <br /> El SEPTIC TANK 1:1 CESSPOOL ❑ LEACHING FIELD ::S PAGE PIT C1 PACKAGE PLANT <br /> ❑ PERMANENT 11 TEMPORARY 11 NEW L'1 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. <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 rul r <br /> nd regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t 8 Aeceived By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE qS <br /> �C^ <br /> 4 LESS \•j{/J <br /> r PRORATION <br /> PLUS <br /> r PENALTY <br /> OTHER <br /> r <br /> I <br /> OTHER <br /> I <br /> 1 33(o3g �� 1 <br /> Received by - - Date Receipt No. Permit No lissuancelDate Mailed Oeliyered <br /> ` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2000 STOCKTON,CA 95201 <br />