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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transterable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is ereby made to carry on business in the jurisdictional area of the tan Joaquin Local Health Distri t _ <br /> r Business Name (DBA) Address �� � -` <br /> a Owner n J r& �' > g - Address—%K Si �4'e <br /> U Firm Partners, Addresses and Telephone Numbers - <br /> aBusiness Telephone No. � ��� +, '- Emergency Telephone No. <br /> -J Contractor Licence No. <br /> LApplicants Name (Print) <br /> Title �?J e Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information 1 <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 Pafking Addres N <br /> 2. ❑ PUMPER YARD <br /> For July 1,. Juhe-30, 19 k <br /> No. of Vehicles Stored <br /> No of Chemical Toilets Stored, 1 <br /> 3. j❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name �'" _ R.S. or R.C.E. No. <br /> Test Location *+ Test,Date/Time <br /> 4. 113 SANITATION PERMIT- <br /> Job" <br /> Job Address/Location f 0 � <br /> Address <br /> 7e . 0 � I <br /> I�:SEPTIC TANK ❑ CESSPOOL LEACHING FIELD; 11SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEWS ❑ REPAIR ❑_-OTHER, 'II <br /> 5.i❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No of Units Equipment Storage/Cleeddning 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-x` <br /> - <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 " +�.', <br /> SIZE- ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. R c J <br /> 0-DRY CLEANING, Chemicals Used/Amount/Mo. <br /> {R t. <br /> I hereby certify that I have prepared thi application and that thew ork will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and gul ions of the San JoaquinoLocal Health District. <br /> ' 6 <br /> APPLICANT'S SIGNATURE X r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: El ANNUALLY 0 PER UNIT 19,PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> µ <br /> LESS <br /> # PRORATION <br /> f PLUS <br /> PENALTY 91 } <br /> ✓.. - ,.--.rt _. r- .. ,,,�, �. ��. �- ..-row... �.-.F..., r,».. <br /> "=mow,-'"OTHER ^"-.. <br /> OTHER <br /> Received by Date - Receipt No.- Permit No. - Issuance Date Mailedelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,.P.O.Box 2009 STOCKT N,CA 95201 - <br />