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Applications Will Be Processed When Submitted Properly Completed.Be Sure ToSignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business int he jurisdictional area of thev an Joaquin Local Health District <br /> OF business Name (DBA) S /�/`G - Address - �� <br /> z Owner �h Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers ►� <br /> a. Business Telephone No. Emergency Telephone No. <br /> a - <br /> Contractor Licence No. <br /> Applicants Name (Print) Title ► Date ZZ` 7 <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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test�Loca�ti r Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location _ZV1 J5• ' <br /> 2✓.t�/� <br /> Owner ��� L`;�fo as '` Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL " 2EACHING FIELD 2-9EEPAGE PIT ❑ PACKAGE PLANT <br /> ©'PERMANENT ❑ TEMPORARY r ❑ NEW "REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1; -June 30, 19 y oV <br /> Type Construction Disposal Site Q <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> r e -Where Certified <br /> Operator Name -•I <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 /> t hereby certify that I hav prepared this applicati nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules and r ulations he San aqui Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY' '. '- <br /> I <br /> Fee Is Due: El ANNUALLY El PER UNIT El PER SITE 0 EACH El January 1 &_ Recei y January 31 © July i R Received By July 31 <br /> REMIT <br /> BASE j EXPLANATION BILLING REMITTANCE �9` $ AMOUNT DUE CHECKED <br /> DATE DATE ",REMITTED AMOUNT <br /> FEE <br /> LESS — <br /> i PRORATION <br /> PLUS <br /> PENALTY <br /> tl n <br /> OTHER iY� <br /> - t <br /> OTHER <br /> 7 -jL=1� <br /> Received„by Date - Receipt No Permit No. issua ce Date1ed Delivered - . <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE., ox 2009 STOCI<TON,CA 952D1 <br />