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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I <br /> APPLICATION <br /> F (For Non-Transferable, Revocable,and Suspendable) f <br /> e <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio h r y m e t rry o sl ss' the jurisdictional area of the S oaq Local Health D' trict <br /> ,n Business Na (DBA) Address � <br /> z Owner t G le JAncze Address <br /> a �� r <br /> Firm Partners, Addresses an a on b rs `7� . <br /> Ov <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title 0CO.4 - Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1.. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i <br /> f For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse Renowal 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 LLp tion Test Date/Time <br /> 4. IT SANITATION PERMIT,��/ <br /> Job Address/L talion <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 3'rACHING FIELD ❑'"SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW I5REPAIR ❑ OTHER <br /> 5" ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified 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 /> I hereby certify that I have prepa th) applicatio an th t the work will'be done in ac \Ya�e with San Joaquin County <br /> ordinances, state laws, and rul and gulat' ns o h a oaquin Local Health District. v <br /> APPLICANT'S SIGNATURE X . <br /> i <br /> FOR DEPARTMENT'USE 0L <br /> Fee IS Due: 11ANNUALLY El PER UNIT PER SITE 13EACH# 13Janua Received By January 31• ❑ July 1 &Received By Jvly 31 <br /> REMIT <br /> BILLING d' REMI ANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE D REMITTED ' <br /> AMOUNT <br /> FEE f <br /> LESS �¢ <br /> PRORATION r <br /> PLUS <br /> PENALTY <br /> OTHER ! <br /> 1 <br /> OTHER <br /> Received by Date Receipt No. mit No. Iss ce :a ailed De vere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O..aox 2 STOCKT N,CA 95201 I <br /> ' .5 <br />