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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 /> Appl icatio 's hereby m de to carry on b iness in the jurisdictional area of the San Joaquin Loc Heal h sTx' <br /> rn Business N me (DBA) t Address - <br /> aOwner i Address 4 <br /> J Firm Partners, Addresses and Tele hone Numbers <br /> s a Business Telephone No. 3� 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 OC\ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> k For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> I 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 /> r <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R,C.E. Name R.S. or R.C.E. No. Wit. <br /> Test Location Test Date/Time <br /> 4. )ff SANITATION PERMIT <br /> 16,11"Job Addre Loc tion g <br /> Owner I Address 321 <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br />( PERMANENT ❑ TEMPORARY -NEW ❑ REPAIR ❑ OTHER I V <br /> 5. ❑ CHEMICAL TOILETS For July 1, -r June 30, 19 <br /> Type Construction ! Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> k 6. 13 PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> k Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served MV <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 /> s� n,, <br /> I hereby certify that l have are <br /> this application and that-the work will be done in accordance San Joaquin County <br /> i ordinances, state laws nd r nd Is <br /> of the SJoaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> 7A <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> 1Sx I <br /> Fee IS Due: 11 ANNUALLY ❑ PER UNIT y� PER SITE ❑ EACH ❑ January 1 &Recekv dy 3anuary 31 ❑ July 1 &Received By July 31 <br /> I- i REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE D TE IT ED AMOUNTp <br /> i. FEE 0000" L� <br /> i LESS <br /> PRORATION <br /> k PLUS <br /> PENALTY �. <br /> OTHER AO 00or <br /> OTHER <br />` Received by Date Receipt No. Permit No Issuance Date Mailed 7De;liv ed <br /> I <br /> APPLICANT—RETURN ALL COPIES TO: EENVIRONMENTAL.HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC TON,-C 96201 <br />