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$ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Nan-Transferable, Revocable, and Suspendable) <br /> I ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Apprrcatro h by mad car usi�thejulhsdictlonal area of the San Joaquin Loci iiWealth Di ict <br /> Business N DBA)_- Address Q .r 4 <br /> z Owner Address a <br /> L) Firm Partners, Addresses and Telephone mb <br /> 0. Business Telephone No.' —.—Emerge ncy.-Teleph on eNo. - <br /> ,. -j Contractor Licence No. <br /> Applicants Name (Print) AAW <br /> l Title Date U <br /> Please check Applicable Category(1-7) and Fill in the Required Inlormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> t 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 /> I, <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> T No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name - -- A R.S. or R.C.E. No.. <br /> Test Location Test Date/Time <br /> 4. /ol SANITATION PERMIT <br /> Job Addr Lo tion <br /> C <br /> Owner - Address <br /> - CLt <br /> _ C] SEPTIC TANK 11CESSPOOLLEACHING FIELD `SEEPAGE PIT ❑PACKAGE PLANT C <br /> f ; PERMANENT ❑ TEMPORARY 11 NEW REPAIR ❑ OTHER C <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 /> F 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. �� Q <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> a I-,.hereby certify tha have repa this appiicatio and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la s, and s d reg la ns o she San aaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> f - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> - BASE EXPLANAT ON AMOUNT DUE CHECKED <br /> DATE- DATE REMITTED - <br /> AMOUNT <br /> r <br /> FEE r_ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER , <br /> .. T <br /> OTHER' S` <br /> D, 3a p <br /> Received by - Date Receipt No. Permit No, IssuartayDate Mailed Deliver <br /> APPLICANT—RETURN ALL cOPIEsTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Boa 2009 STOC ON,CA 95201 <br />