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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.—` m <br /> T APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE ` <br /> LIQUID WASTE <br /> i Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rBusiness Name (DBA) <br /> z Owner Address - 1 Lane <br /> a Address 113 <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No, <br /> i Contractor Licence No. Emergency Telephone No. 95] 402 <br /> L Applicants Name (Print) Title f)rm a r W <br /> Please check Appiicable Gaie o Date <br /> g ry(1-7)and Fill in the Required. Information ^` d <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION_-(FOR EACH VEHICLE) V <br /> For July 1, June 30, 19 Disposal Sites# s <br /> Description(Make/Yr., Color) r <br /> Serial No, CAL. License No. <br /> Capacity � CAL. Liccrsse Renevral No. <br /> Gal., Weights & Measures No, <br /> 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 /> 3. ❑ PERCOLATION TEST '"�. <br /> R.S. or R.C.E. Name <br /> Test Location ' # <br /> ^�Nest e/Time <br /> 4. ❑ SANITATION PERMIT t � �y r fie+•, ,~� <br /> Job Address/Location ; <br /> Owner <br /> Add essY'�*',- <br /> SEPTIC TANK El SSPOOL '� <br /> 1 t LEAG�HING FIELD EPAGE PIT 1-1PACK E PLANT i <br /> PERMANENT ❑ TEMPORARY, NEWS REPAIR - OTHER <br /> 5 S <br /> . 11CHEMICAL TOILETS For July 1, -Jun 30, 9 � <br /> Type Con struction i t Disposal Site rn <br /> No. of Units Z Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGEl'TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name ` J, <br /> Plant Location _ _ <br /> Where Certified N <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 /> k <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> ordinances, state laws, and rules and regulations of the San Joaquin oval Health District. with San Joaquin County <br /> APPLICANT'S SIGNATURE X <br /> i <br /> { <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 161 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION -BILLING REMITTANCE $ REMIT <br /> DATE - DATE REMITTED AMOUNT DUF CHECKED <br /> FEE �� AMOUNT <br /> LESS � GKr <br /> PRORATION <br /> PLUS <br /> PENALTY + <br /> OTHER <br /> OTHER <br /> Received by Date S 30 1� <br /> Receipt Nv- Perrni[No. Issuan a Date n / <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed eliver ' <br /> v �. 1601 E.HAZELTON AVE.,P.O.Box 2oog 'STOC ON,CA 201 <br />