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y Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. `, + <br /> APPLICATION <br /> VI- (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> upUlo WASTE <br /> Applscat io 's hereby ade to carry on business in the jurisdictional area of the San Joaquin Local Health District S <br /> �L <br /> , <br /> v;Business Name (DBA) aT` ao�/� Address <br /> NJ <br /> Address G S S. `�'� If <br /> aOwner r <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) <br /> ♦ / Title ST 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 Vs <br /> 3. ❑ PERCOLATION TEST Uy <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location O' <br /> i 4. <br />` � SANITATION PERMIT CQ <br /> Job Add�ess/Location & ' <br /> iT <br /> Owner Cr;U_iz/'Fk !�f <br /> Address , UE <br /> ` <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD KSEEPAGE PIT ❑ PACKAGE PLANT <br /> �IPERMANENT ❑ TEMPORARY ❑ NEW X REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction � - Disposal Site <br /> No. of Units Equipment Storage/Cleaning L-o-ca-tion(s <br /> ) <br /> r 7 <br /> I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1 <br /> Where Certified <br /> Operator Name <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 /> 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, d r I and regulations of,the an 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 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE " 5:) ¢¢ <br /> LESS <br /> PRORATION �y <br /> PLUS o <br /> L PENALTY <br /> F OTHER - <br /> OTHER. <br /> k <br /> fReceived by Date Receipt No. Permit No, - Issuance Date Mailed Delivered <br /> PP APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 PTOCKTON,CA 95201 <br />