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I 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 SEPTAGE <br /> LIQUID WASTE <br /> Applicatin its hfreby made to carry on usiness in the urisdictional area of the San Joa uin Local Health District G <br /> N Business Name (DBA) /� s G� iX/C S„ � � Address_%2 <br /> aOwner_,F�• <br /> J Firm Partners, Addresses and Telephone Numbers <br /> r7 <br /> Business Telephone No. zg4y : - . Emergency Telephone No. <br /> Contractor Licence No. /77 /E} <br /> L Applicants Name (Print) 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, 19 Disposal Sites -� <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No.' <br /> Capacity Gal.,'Weights & Measures No. <br /> I <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 Location - Test Date/Time <br /> 4. aSANITATION PERMIT <br /> ` Job Address/Location <br /> Owner �&0I2zj Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD a SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> i <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> t 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> ' Operator Name Where Certified <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., C1 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, a_ rule <br /> and re tion of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July.31 <br /> ` <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATIONAMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> w FEES <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER ^; <br /> OTHER <br /> -7`i---X10 I cvt k 171 <br /> Received by Date- Receipt No. ,Permit No�- - Issuance Date Mailed efivereIF <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK N, A 201 / <br />