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roperly Completed. Be Sure To Sign The Application. <br /> Applications Will Be Processed When Submitted P <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendabie) SEPTAGE rt <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> R <br /> Application is her y made to carry on business in the jurisdictional area of the San Joaquin Local Health District �Zc7 <br /> �S <br /> rBusiness Name (DBA) Address <br /> zz Owner <br /> Address <br /> c Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. – D Emergency Telephone No,0. i <br /> Contractor Licence No. Z r 7— <br /> Applicants Name (Print) <br /> Titled Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites 1 <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 /> No of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Loca on Test Date/Time <br /> q. L'TJ SANITATION PERMITi <br /> Job Address/Location 4CT +` <br /> �T, L3YI S�/d Address <br /> Owner [] PACKAGE PLANT <br /> ❑ SEPTIC TANK 11 CESSPOOL 11 LEACHING FIELD SEEPAGE PIT ❑ <br /> 101 PERMANENT 11TEMPORARY ❑ NEW 13-REPAIR OTHER Z <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> ii <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> g, ❑ PACKAGE TREATMENT PLANT For July i, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 /> 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, d rules an regulations oft San J aquin Local Health District- . <br /> APPLICANT'S SIGNATURE _ <br /> FOR DEPARTMENT USE ONLY <br /> d By <br /> Fee IS Due: 13 ANNUALLY ❑ PER UNIT [j PER SITE ❑ EACH ❑ January 1_&Received y anu ry 3 Jul 1 Rece REMITuiy 31 - <br /> F EXPLANATION BILLING REMITTAN E A U DUE CHECKED <br /> BASE DATE DATE r E I AMOUNT <br /> FEE <br /> LESS <br /> PRORATION +� T <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> I"' - APPLICANT--RETURN ALL COPIES TO: ' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.O. T�6 nT�ON,CA�D� <br />