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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> t_ APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is r"eby made to c rry on business in theprisclictional area of the San 7o Joaquin Health District <br /> y Business Name (DB Address�(1 <br /> 4 Owner <br /> -2 ddress- <br /> J Firm Partners, Addresses and Telephone Numbers - <br /> aBusiness Telephone No. s—/d S Emergency Telephone No. <br /> Contractor Licence No. s CJ <br /> Applicants Name (Print) c Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required In ormation F <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) —=9 <br /> �` Disposal � t <br /> For July 1, June 30,;19 Sites <br /> Description.(Make/Yr.'Color) <br /> Serial No. .� ­ <br /> CAL. License No. CAL. License Renewal No. <br /> . �� <br /> Capacity� Gal.,Weights & Measures No. <br /> Equipmeint,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.ZR ­. NameR.S. or R.C.ENo. <br /> Test Date/TimeTesn4. TATION PERMIT ` '! <br /> Job Address/Loc oon — — <br /> J � t Address <br /> Owner 11 PACKAGE PLANT ~ <br /> 1:1 SEPTIC TANK 11 CESSPOOL LEACHING FIELD SEEPAGE PIT 11 OTHER Q I <br /> ❑ PERMANENT 13 TEMPORARY ❑ NEW O/REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 P <br /> Type Construction pmenDispo <br /> No. of Units se I Site Ile <br /> Equipment Storage/Cleaning Location(s) ` r <br /> r ' <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, --June 30, 19 <br /> it L3 Where Certified dill, �I <br /> Operator Name ..--j TA <br /> Plant Location <br /> Plant Capacity No. Units'Served <br /> 7. 13 LAUNDRY For July 1, -June 30, 19 <br /> 4,k'N <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> i <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 rules an ^'ulations of the/Sa oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ` <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Fee is Due..[] ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &ReceivedREMITuly 31 <br /> BASE EXPLANATION DATE <br /> REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 1 <br /> t OTHER <br /> OTHER <br /> i <br /> Received by Date Receipt No. Permit No Issuaince Dae Mailed De we d <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P:O.Boll 2009 6 <br /> TOC TON,CA 5201 <br />