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i - - Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. :. <br /> APPLICATION " <br /> a (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> 1 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) J> A 219R4_15 A/ e Address AO'­ R 57x� � <br /> ~ <br /> z Owner Address <br /> 4 <br /> :,Firm Partners, Addresses and Telephone Numbers <br /> I .¢ Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) F 1­0A U,;0 OX Title c S�/M Date �� ' <br /> I Please check Applicable Category (1-7) and Fill in the Required Information <br /> fl 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. CAL. License No. CAL. License Renewal No, <br /> Capacity 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 w <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 /> P <br /> 't 4. SANITATION PERMIT <br /> Job Address/Location 8/ —'1-3 �,— =-- �`:1���'� <br /> Owner aA&25 C e,67",-0­;;V Address <br /> SEPTIC TANK ❑ CESSPOOL Jk LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> �I PERMANENT ❑ TEMPORARY J4 NEW ❑ REPAIR ❑ OTHER -4 <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 /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name' Where Certified <br /> l _Plant Location <br /> i Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., C3 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r 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 oft San quip Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY 0 PER UNIT XPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED �j AMOUNT <br /> FEE `7 S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> _ <br /> 77-910 <br /> 1 Received by Date Receipt No <br /> - Permit No Issuance Date" Mailed De6v ed <br /> 1 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 'TO <br /> TON,C 95201 - <br />