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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 /> F Appiicati is her by de to carryon business in the jurisdictional area of the San Joaquin Local Health Dist rl t <br /> y Business Name (DBA) O O— !�% 5 zJ/ <br /> z Owner (,r�CLC/f } Address � . <br /> a _ Address d 5 S ,dF4ziC:7T <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Emergency Telephone'No. <br /> Contractor Licence No. - <br /> L Applicants Name (Print)—d7,777 Title �Tr Dater <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. 'E] 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. Liccrlse 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. Name R.S. or R.C.E. No. <br /> t <br /> j Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location <br /> Owner li l Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD XSEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR 11 OTHER <br /> 5. 1-1CHEMICAL 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?e1nand,regulations of the Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r <br /> FOR DEPARTMENT USE ONLY <br /> I '. <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> BILLINGREMITTANCE $ _ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS l� <br /> PRORATION <br /> PLUS <br /> I PENALTY t <br /> y <br /> OTHER ' <br /> . i <br /> OTHER : <br /> } <br /> i <br /> Recewed by Date Receipt No. Permit No.' Issuance Date Mailed Delivere <br /> APPLICANT—RETURN ALL COPIES TO:,:�ENVIRONM1:NTgL,HEALT PERMIT/S RVICES 1601 E. AZELLTTO"AVE.._ � P.O.Box 2009 STOCK N,CA 5201 _� <br />