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ApplicationsWill 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 /> 5 \ ' <br /> Application#sreby a e to carry a usi. ss in the jurisdictional area of the San Joaquin Local Health D' rict <br /> F Business Name (DBA) Address <br /> — <br /> z Owner <br /> 2 Firm Partners, Ad resses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> J Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ^Jt <br /> For July 1, June 30,:19, Disposal Sites - <br /> Description(Make/Yr., Color) j <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. t� <br /> Capacity Gal., Weights & Measures No. x <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored r <br /> No. of Chemical Toilets Stored f �` <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No.i <br /> Test Location Test Date/Time" <br /> 4. ❑ SANITATION PERMIT <br /> Joh Address/Location 16 <br /> Owner �Ateli 71 et 416 e D,..�,` A dress i <br /> SEPTIC TANK El CESSPOOL CC'LEACHING FIELDI ❑ SEEPAGE PIT ❑ PACKAGE PLANT t <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Constructiont - <br /> Disposal Site <br /> No. of Units ' '- Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT 'For July 1, -June 30, 19 <br /> Operator Name ~ Where Certified <br /> Plant Location t I <br /> Plant Capacity _4 No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑Less Than Ail Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this appli 'on and.that the-work will b don Inn.,kordance with San Joaquin County <br /> t ordinances, state laws, and r and gulati of he San Joaquin cal a th DijJs ICI <br /> APPLICANT'S SIGNATURE X +t <br /> FOR DEPARTMENT USE(Qr" <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH Ja jrn�� 1 &Received By January 31 © July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMI Al, $ <br /> REMIT <br /> DATE DA' REMITTED AMOUNT DUE CHECKED i <br /> AMOUNT <br /> FEE <br /> � ( I� ao <br /> ``ii <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> O_T* �. <br /> OT4�ER / <br /> Received by Date Receipt No Permd No. 4suancd Da-tom Mailed Bel <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ` <br />