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i 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 r <br /> LIQUID WASTE 1 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,, Business Name BA) Address <br /> ,a Owners Address� 3 7 <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No, <br /> Contractor Licence No. <br /> �Applicants Name (Print) +&'11 C­0 d �> r Title 1:9 4,.-Ieo�e Date <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 n� <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. t <br /> Test Location Test Date/Time r.t 11f <br /> �4. ❑ SANITATION PERMIT t <br /> 43ob Address ation # <br /> Owner Address Q I <br /> ❑ SEPT16 TANK ❑ CESSPOOL LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW Ik REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 f <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. 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> s , <br /> I hereby certify that I have pre ed this application and that a work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r s nd regulations of the San a in Local Health District. <br /> APPLICANT'S SIGNATURE X �' �` � <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,tiny 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE - DATE REMITTED AMOUNT DUE CHECKED f <br /> �' ralAMOUNT�c* <br /> FEE LI r�Q Ah <br /> 3 fQ 8 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> OTHER <br /> Received by Date Receipt No, Permit No. Issuance Dateiled Deliver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P. .Box 2009 STOCKTON,CA 95201 <br />