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I Applications Will Be Processed When Submitted Properly Completed. Be SureToSign Inewppucauon. <br /> ? APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati Is hereby a to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> 01� ^' l� <br /> H Busineacne (DB ) std/C' ` / _Address <br /> ss S� <br /> Owner i .IJJ . LGj Address s< og <br /> Firm Partners, Addresses and Teley_hone Numbers ` d <br /> a Emergency 1 <br /> Business Telephone No. enc Tele g y hone No. <br /> P <br /> Contractor Licence No. 44 1(, ! <br /> Applicants Name (print) Z� s Title I 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) 's <br /> Serial No. CAL. License No. - CAL. Llcc;nse Renewal No. <br /> Capacity Gal.i,Weights & Measures No. ti <br /> Equipment Parking Address <br /> l 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 <br /> No. of Vehicles Sjored l <br /> No. of Chemical Toilets Stored I! ` <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location ii, Test Date/Time <br /> .r <br /> 4. 1 rSANITATION PERMIT ,.. 7r6 e_ / <br /> Job Address/Lova ' <br /> Owner It Address <br /> i ❑ SEPTIC TANK ❑ CESSPOOL ;iLEACHING FIELD J9?.,_,�6CKE PLANT <br /> PERMANENT ❑ TEMPORARY 11 ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 11,, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT i For July 1, -June 30, 19 <br /> I Operator Name I Where Certified <br /> li ¢ <br /> Plant Location <br /> Plant Capacity �N No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE! ❑ Less Than 1,000 Sq. Ft., i❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I r <br /> w <br /> ,I <br /> h I hereby certifythat I ared this'application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state I s, an and regulation the n Joaquin Local Health District. k t <br /> APPLICANT'S SIGNATURE <br /> li <br /> h, <br /> .I� <br /> 4 FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 1:1 PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT= <br /> BILLING REMITTANC $ AMOUNT DUE CHECKED <br /> BASE i EXPLRNATI N - DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS _ <br /> PRORATION <br /> PLUS <br /> PENALTY / <br /> OTHER <br /> OTHER <br /> r a 6677 3// <br /> Received by - -Date I Receipt No- Permit No, swan a Date Mailed elivered <br /> APPLICANT—RETURN-ALL COPIES_T _ENVIRONMENTAL HEALTH PERMIT/SERVICES x'1601 E.HAZELTON AYE.,P.O.Box 201)9 STOCKT N,CA 91 01 z <br />