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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Yom,- (For Non-Transierable, Revocable,and Suspendable) <br /> W <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> ' � LIQUID WASTE <br /> Application is hereby made to carry QA businep in the jurisdictional area of the S n Joa in Local H alth trio <br /> m Business a (DBA)K;-vLC 2Gt/Y.� �- Address 9 F <br /> zOwner c Address / a <br /> J Firm Partners, Addresses and Tel hone Numbers 97LF C O <br /> E Business Telephone No. r3 3 3 Emergency Telephone No. <br /> J Contractor Licence No. �5 <br /> L Applicants Name (Print) !c�' p�� Title W Date <br /> Please check Applicable Category (1-7)and Fill in the Required 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 /> I Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address n <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stored v <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 /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT ,r <br /> Job Addre / cation _ <br /> Owner ��—�- ����� Address ./+ <br /> SEPTIC TANK ❑ CESSPOOL B-CEACHING FIELD B-19EEPAGE PIT ❑ PA -AGE PLANT lr <br /> N ❑ PERMANENT ❑ TEMPORARY O'NEW ❑ REPAIR ❑ OTHER <br /> i 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 1 <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 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 /> r: <br /> I hereby certify that I have prep this app . ation a d that the work will be done in accordance with San Joaquin County <br /> a ordinances, state laws, and ru dregulat' s f t San Joaquin Local Health District. <br /> dr <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT gg PER SITE ❑ EACH ❑ January 1 &Received ByJanuary31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> F BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE e/- <br /> LESS LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER . <br /> CV <br /> 7 <br /> Received by - Date Receipt No. Permit No. Issuance Date Mailed 'Derive 7--Al' �+y 7L <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 01 E.NAZELTON AVE.,P.O.Box 2009 STOCK ON,_CA 95201 JJ <br />