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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 ' hereby maktqto carry on bu 'ness in the judsdictional area of theoa in Local Health District <br /> Lo Business Nam BA) Address <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Number <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print} Title Date '^ <br /> Please check Applicable Category(1-7)and Fill in the Requir d 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. Licc�ise 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.ZR.0Name R.S. or R.0.E. No. <br /> Tesn Test Date/Time <br /> 4. TATION PERMIT _ <br /> Job Address/ oc 'on S <br /> Owner Address } <br /> ❑ SEPTIC TANK ❑ CESSPOOL C1 LEACHING FIELD �� PAGE PIT C1PACKAGE PLANT <br /> ❑ PERMANENT 13 TEMPORARY ❑ NEW 9� EPAIR ❑ 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 V� <br /> Operator Name Where Certified ^� y <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 rules gul ' sM10tan aquin Local Health District. <br /> "f <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recei ed BI uary 31 ❑ July 1 &Received By July 31 # <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMI AMOUNT <br /> FEE ys <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 14 <br /> a-� <br /> Received by Date Receipt No. Permit No ssuance Date Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Box 2008 STOCKTON,CA.45201 <br /> 91!e-W L,�L �V-3 . 6t!S'S I <br />