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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 SEPTAGI _ <br /> LIQUID WASTE <br /> Application is hereby m e to carry o sines 0 the jurisdictional area of the San Joa in Local Health District <br /> H Business a (DBA) Addr�e7ss C <br /> aOwner lG Address �✓� t 4 <br /> Firm Partners, Addressesand T ephone Numbers <br /> CL <br /> Business Telephone No. -3��g Emergency Telephone No. .�4 -+G <br /> Contractor Licence No. <br /> �Applicants Name(Print) Title Dawto, Date <br /> Please check Applicable Category (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 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 to <br /> 3. ❑ PERCOLATION TEST _S1 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. + <br /> Test Location Test Date/Time <br /> 4. MSANITATION PERMIT <br /> Joh Addre Locatio O ' d64Air- Akgt ' <br /> Owner Address 1 r" / ' <br /> , <br /> ElSEPTIC TAK ❑ CESSPOOL ❑ EACHING FIELD ElSEEPAGE PIT' ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY L7 NEW ❑ REPAIR ❑ 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 f <br /> Plant Capacity No. Units Served ` t <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 a plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and and regu s the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PX PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ JWY t &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE D J y� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Iyate Mailede iv red �� 7 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTO NAVE.,P.O.Box 2009 5T0 KTON, A 95201 <br />