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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGi <br /> LIQUID WASTE <br /> Application is hereby ma a to carry on business in the jurisdictional area of the San Joaq in Lo al ealth Dis I ,,• <br /> rn Business Jame (DB AddraOwner Address -2Firm Partnesse and T lephone Numbers <br /> a Business TNo. Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> a LApplicants Name (Print) -y 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 O' <br /> i Description(Make/Yr., Color) <br /> 1 <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 /> I No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E~No. a <br /> Te Location Test Date/Time " <br /> 4. SANITATION PERMIT / <br /> Job Addre s/ ocatio <br /> Owner Address <br /> .test SEPTIC TANK CESSPO X LEACHING FIELD ❑ SEEPAGE PIT T PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR y ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site, <br /> s No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified rJ n <br /> Plant Location <br /> Plant Capacity No. Units Served �( N <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft, a <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> M I hereby certify that I have prepared this app atio and that the ork will be done in accordan (4n <br /> ordinances, state laws,.arld rules a regulate s of San Joaqui Local Health District. <br /> a <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Sanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - .AMOUNT <br /> FEE �� —s <br /> LESS <br /> PRORATION <br /> r PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> Received by Oale Receipt No. VLrrrhit No. Issuance Date Mailed D Iver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 `STO N,CA 95 1 <br />