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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 i Wreby made carry onus in e I ' dictional area of the San Joaquin Local Health Distri <br /> -A-0—,,Business Name BA) �C— Address d 7 7 <br /> z Owner ddress Q <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> Q. <br /> Business Telephone No. c�I O Emergency Telephone No. <br /> Contractor Licence No. ZCV Applicants Nan U Title �� ^� Date m —Cf <br /> _If I <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q� <br /> For July 1,� .� June 30, 19 Disposal Sites <br /> Description(Make/Yr.; Color) <br /> Serial No" ' .CAL. Licens 'No. CAL. License Renewal No. <br /> +. <br /> _Capacity Gal., Weights &Measures No. <br /> w ♦ fl - t i <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 /> TestLope<On Test Date/Time--- - <br /> 4. O SANITATION PERMIT j <br /> �- •�f� -•rte <br /> Job Address/Location '> -7 4-7 21 <br /> OwnerAddress'� <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACH_ING FIELD 2SEEPAGE PIT ❑ PACKAGE PLANT* <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW �'" A ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For_July 1, -June 30',19 <br /> Type Construction Disposal Site <br /> No, of Units f' I Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name ;- Where Certified <br /> Plant Location J <br /> Plant Capacity No. Units Served tai <br /> 7. ❑ LAUNDRY For July 1, :June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq F't., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ♦ <br /> 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 and regulations a an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> M <br /> I FOR DEPARTMENT USE 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 /> BILLING REMITTANCE $BASE i EXPLANATION DATE DATE REMITTED AMOUN DYE CHECK ' <br /> AMOUNT <br /> FEE I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />