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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAG> <br /> LIQUID WASTE 0 <br /> Applicalio is hereby ade to car n bu in s in the jurisdictional area of the S, Joaqu' Local Health District N <br /> rBusiness (D.BA) M Address /� r r <br /> to I <br /> aOwner Address I <br /> J Firm Partners, Addresses and Telephone Numbers01 1 <br /> £l 7 y 3 G <br /> aBusiness Telephone No. ( Emergency Telephone No. <br /> Contractor Licence No. 0 SIE <br /> Applicants Name (Print) CF Title ��`" 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, 191$ Disposal Sites v <br /> Description(Make/Yr., Color) �� 6 <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity �M, Gal.,Weights & Measures No. <br /> Equipment Parking Address C <br /> 2. ❑ PUMPER YARD Q <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. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Lobation Test Date/Time <br /> 4. M SANITATION PERMIT �� p <br /> Job Address ocation � <br /> Owner _ �l j Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 9FREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -,lune 30, 19 <br /> r <br /> Type Construction Disposal Site <br /> No. of Units-* ,II Equipment Storage/Cleaning Location(s) <br /> 6. 1:1PACKAG TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name �\ �M Where Certified <br /> Plant Location �M <br /> Plant Capacity �M No. Units Served <br /> 7. ❑ LAUNDRY For my 1, une 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> d <br /> I hereby certify that I have prep is applicatio a th t the work will be done in accordance with San Joaquin County <br /> ordinances, stale lawls, and rul a regulations o h a Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X !I" <br /> i FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 1:1ANNUALLY L�, PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 .❑ July 1 &Received By Jury 31 <br /> '1 BILLING REMITTANCE $ REMIT <br /> p <br /> BAEXPLANATION AMOUNT DUE CHECKED <br /> Ij. DATE DATE flEMITTEO AMOUNT <br /> FEE <br /> r v <br /> I LESS ! <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ( OTHER II� <br /> f � p <br /> I� 7eA—qo S t 7 , <br /> Received by D�hte Receipt No, Permit No. ssuance ateF' Maile—d — <br /> Delivered , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES <br /> �1 1601 E.HAZELTON A 2009 Delivered <br /> ,CA 95201 E <br /> 0 G7` <br />