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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> •-• APPLICATION <br /> (For Non-Transferable, Revocable, and Sus endable <br /> P ) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE ff// <br /> LIQUID WASTE F <br /> Applicatio 's hereby Ade to carry pn busi ss in the jurisdictional area of t �fSa Joaquin Local Heal District f <br /> ,„Business Name (DBA) .Address C1' ry']-r11 <br /> I.- <br /> Owner Address <br /> j Firm Partners, Addresses and Telephone N mbers <br /> IL Business Telephone No. Emergency Telephone No. CIA t <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 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 /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> B <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 ocation Test Date/Time <br /> 4. SANITATION PERMIT f <br /> Job Address/Location W <br /> Owner 61E LC—wisAddres v --� I <br /> ❑ SEPTIC TANK ❑ CESSPOOL %LEACHING FIELD .SEEPAGE PIT ❑ PACKAGE PLAN <br /> ❑ PERMANENT ❑ TEMPORARY 13 ANEW REPAIR ❑ OTHER A I <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 /> 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. M <br /> 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 les and re Iations o he an uin Local Health District. <br /> APPLICANT'S SIGNATURE X t } <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ FACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE - EXPLANATION DATE GATE REMITTED AMOUNT DUE CHECKED '- <br /> AMOUNT <br /> FEE V <br /> LE5S r <br /> PRORATION <br /> PLUS U <br /> PENALTY <br /> i <br /> OTHER <br /> p <br /> OTHER <br /> Received by 'Date-"-_- --.w,Receipt No._:` -- Permit No, Issuan a Date Mailed D i ere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT)SERVICES <br /> 1601 E..HAZELTON AVE.,P.O.Box 2009�-STOC ON,GA 9 01 <br /> — <br />