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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign-The Application. <br /> r APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is ereby made to carry on buss ss in the jurisdictional area of the S Joaq Local Health District <br /> cn Business Name (DBA) E �� /rCl JL Z_ Address ee l �l Y_ tilCG.ae <br /> Q Owner Address���� ��O Z---t4 <br /> f lG <br /> i 0 Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. a <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title e�_i NG Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q <br /> For July 1, June 30, 19 Disposal Sites - C <br /> Description(Make/Yr., Color)- <br /> �1 <br /> Serial No. CAL.License No. CAL.. License Renewal No. <br /> Capacity Gal., Weights & Measures No. W <br /> ti <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD T <br /> For July 1, June 30, 19 - <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored-` <br /> 3. ❑ PERCOLATION TEST <br /> ,r _ <br /> R.S. or R.C.E. Name R.S. or R.C.E. Na. <br /> Test Location =- _ Test Date/Time <br /> 4. ❑ SANITATION PERMIT `/� <br /> Job Address/Location— <br /> fE er Address <br /> PSEPTIC TANK ViCf�SSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT. ❑ PACKAGE-PLANT <br /> ❑ PERMANENT ❑ TEMPORARY . �❑ NEW ❑ REPAIR ❑ OTHER <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction ` i 1 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 <br /> I Plant Location <br /> Plant Capacity No. Units Served <br /> 0 7. ❑ LAUNDRY For July 1, -June 30,19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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, s6te laws, and rules andoregi.latico of the San Joaquin-Local Health District. <br /> APPLICANT'S SIGNATURE-X <br /> r FOR DEPARTMENT USE ONLY <br /> F1cr <br /> t Fee Is DUe: ❑ ANNUALLY PER UNIT lay PER SITE ❑ EACH ❑ January 1-&Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING -REMITTANCE _ REMIT <br /> BASE EXPLANATION " DATE Y DATE REMITTED AMOUNT DUE CHECKED - <br /> AMOUNT <br /> FEE r Uj I. <br /> LESS ,I <br /> ,,PRORATION <br /> PLUS <br /> PENALTY 1 " <br /> OTHER"-- <br /> " VV <br /> . ,. r <br /> i <br /> OTHER <br /> u 303 r <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> ;4/_—z <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTALHEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKY N,CA 9520 <br />