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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application! <br /> APPLICATION `S Ii <br /> gh . (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGI <br /> LIQIAD WASTE <br /> r Application is hereby made to carry on usines the ju i ictional area of th San o quip Loc I Health District: <br /> Business Name (DBA) <br /> I�: L n Addres C_ ,� <br /> z Owner Address II <br /> a 11 <br /> J Firm Partners, Addresses and Tele hone Numbers <br /> CL Business Telephone No <br /> - Emergency Telephone No. <br /> rye Contractor Licence No. �f <br /> .Applicants Name.(Print) - L- Title Date "i r <br /> f_-„Please check Applicable Category (1-7) and Fill in the Required Information <br /> 21.'-❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. I� CAL. License No.-� CAL. Licc,-,se Renewal No. II <br /> Capacity i� Gal.,Weights &'Measures No. '. I <br /> _..Equipment.Parking Address I� II <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored A <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S' or R.C.E. Name II R.S. or R.C.E. No. ! .4 <br /> Test Location Test Date/Time <br /> 4. SANITATION <br /> � Job Add ress/Locat!orlrl%- <br /> Owner Address <br /> )� <br /> SEPTIC TA K CESSPOOL LEACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW B&AEPAIR ❑•-OTHER" - <br /> 5. :❑ CHEMICAL TOILETS Fpr July 1, -June 30, 19 <br /> Type Construction Disposal Site _ <br /> No.of Units it Equipment Storage/Cleaning Location(s) <br /> 6.r C] PACKAGE TREATMENT PLANT For July 1, -June 30, 19 $ «- <br /> I Operator Name II - — Where•Certifled <br /> - <br /> Plant Location <br /> "Plant Capacity II No. Units Served ' <br /> .. ;❑ LAUNDRY For July 1, -,lune 30, 19 ¢ <br /> 'TSIZE: ❑ Less Than 1,000 Sq.I!Ft., ❑ More Than 1,000 Sq. Ft. , <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.. <br /> ` I hereby ce i y t I'have preparN this applicat nand that the work will be done in accordance with San Joaquin County <br /> ordinances, ate law nd ru s n s- the_ n_J- . quin_Local_Health District. _ r• �c <br /> .APPLICANT'S SIGNATURE -' I <br /> 1' --, J <br /> I , <br /> FOR DEPARTMENT USE ONLY�-- -� <br /> t - �� ,l� <br /> .Fee IS Due: ❑ ANNUALLY1I ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &'Received By July•31 ' <br /> II' BILLING REMITTANCE $ REIv11T <br /> BASE. EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT... <br /> 'FEE S. <br /> o <br /> LESS I <br /> PRORATION <br /> PLUS I� <br /> PENALTY <br /> Y OTHER <br /> r OTHER <br /> t _ , <br /> . m 10 <br /> Received by 19ate Recelpl No. Permit No. �, Issuance Date"I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2008 5TOGKTON,CA 95201 <br /> y _'� �� ` - w <br />