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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 is hereby made to carry on business in the jurisdictional area of the S; ►oaquin Local Health District <br /> rn Business Name(DBA) _��� IR _Address IG' <br /> aOwner �' r Address <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No, Emergency Telephone No. <br /> Contractor Licence No. <br /> i L Applicants Name (Print). Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> t. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. <br /> CAL. License Renewal Na. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored a .y <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 /> K, Test�L'ocation I Test Date/Time <br /> 4. D SANITATION PERMIT r # <br /> E Job Address/Location .. Ile <br /> I O,.,_w, n�er-- �( Address,. <br /> ASEPTIC TANK ❑ CESSPOOL x, -16a-LEACHING FIELD ❑ SEEPAGE PIT+ ' ❑ PACKAGE PLANT f �! <br /> ❑ PERMANENT ❑ TEMPORA Y— ❑ NEW' [J.-REPAIR, �'4❑ .OTHER �( s �Z <br /> .- <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30 19 r <br /> F <br /> Type-Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July-1, -June 30'19 <br /> Operator Nam <br /> P s e Where Certified <br /> Plant Location - <br /> Plant Capacity No. Units Served "— <br /> 7. LAUNDRY For July 1, -June 30, 19 IF 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMo. <br /> z - <br /> Thereby certify that I have prepared this application and that the work will be done in accordance with San Joaqui ) <br /> ordinances, state laws, and rules and reg (tions f the San o quin Local Health District,, <br /> !�e y 4 � <br /> APPLICANT'S SIGNATURE X '- <br /> 5j� <br /> FOR DEPARTMENT USE ONLY <br /> ©I <br /> Fee IS Due: 'f{NNUALLY ❑ PER UNIT ❑ PSR SITE ❑ EACH ' ❑ <br /> - January 1 8 Received By JanWary 31 ❑ July,1 &Received By July 31 <br /> BILLING= 'REMI <br /> DATE T �± <br /> RASE EXPLANATION' REMITTANCE $ AMOUNT DUE CHECKED <br /> a DATE REMITTED <br /> ` AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> 4 PLUS <br /> PENALTY 1 <br /> OTHER <br /> Receive tl by Date. Receipt No Permit No. Issu nce D to Mailed Deiiven) <br /> Y APPLICANT—RETURN-ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:'HA2ELTON AVE:,P.O.Box 2009 STDCKTON,CA 45201 <br />