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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 /> Applicatio is heret}9i made to c rry o busi ss in the jurisdictional area of the an Joa in Local Health (strict <br /> �;Business Name (DBA) }J Address tet/ f <br /> aOwner Address <br /> J Firm Partners, Addresses and/Telephone Numbers <br /> aBusiness Telephone No. �o v �4� 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 Required Information J <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites I <br /> Description(Make/Yr., Color) <br /> Serial No. I CAL. License No. CAL. License Renewal No. <br /> i <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> i 2. ❑ PUMPER YARD <br /> I For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored .... <br /> 3. ❑ PERCOLATION TEST �J <br /> t <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. C9 SANITATION PERMIT J 1 <br /> Job Address/Location <br /> Owner ccjw ex, Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL -� LEACHING FIELD `�❑-SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY �❑ NEW 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 j 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 rules and regulations of the San Joaquin Local Health District. r <br /> APPLICANT'S SIGNATURE X <br /> { /7/11d 01,. <br /> - r <br /> 4 <br /> F OR DE ARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0 PER SITE ❑-EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $, REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED r <br /> AMOUNT <br /> FEE <br /> LESS LI <br /> PRORATION !t ' <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 />