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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applica *Ujri is hereby ma0e to c rry on business int ejurisdictional area of the, Joa Local He ith District <br /> �;Susiame (DBA < � Address <br /> I.- <br /> Owne Address f <br /> Firm Partners, Addresses and Telephone t4mbers hh <br /> aBusiness Telephone No. 571 0S_ Emergency Telephone No. W <br /> Contractor Licence No. <br /> Applicants Name (Print) t Title Date 1 <br /> Please check Applicable C06gory (1-7) and Fill in the Required Information <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 Rencwal 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. Name R.S. or R.C.E. No. Q <br /> Test Loc ion Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/location <br /> Owner Address���� — <br /> ❑ SEPTI NK 11 CESSPOOL LEACHING FIELD L7 SEEPAGE PIT ❑ PACKAGE PLANT <br /> P-PERMANENT ❑ TEMPORARY ❑ NEW 2 FIEPAIR ❑ OTHER <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. <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 ules and reg lati s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jwy 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> Lt's AMOUNT <br /> FEE <br /> U <br /> LESS <br /> PRORATION — <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss nee Dat Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELT AVE_P.O Box 2009 STD KION,C 95201 <br />