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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 /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> FBusiness Name (DBA) d�; dtrTc nF!/ Address' r_2 � 0 6�� ���� r <br /> zz Owner Address <br /> �,� � - <br /> J,Firm Partners, Addresses and Telephon Numbers - l� <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. �- <br /> L Applicants Name (Print) Title Date t <br /> Please check Applicable Category (1-7) and ill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> E <br /> Description(Make/Yr., Color) <br /> f Serial No. CAL. License No CAL. License Renizwal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMP.ERYARD `, <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored 1 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name _ R.S. or R.C.E. No. <br /> i <br /> Test Location - Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location T7 _.�__._.. _�/S r/ . ,vT11,e fP <br /> Own�r Address <br /> I I�SEPTIC TANK ❑ CESSPOOL ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ; <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> j 5. ❑ CHEM.ICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction _Disposal Site. <br /> No. of Units f Equipment Storage/Cleaning Locations) t <br /> 6. ❑ PACKAGE TREATMENT-PL"ANT For July.1„-June 30, 19 J <br /> Opera(or Name <br /> .�.; Where Certified <br />{ Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30;49— �-- - <br /> a SIZE: ❑ Cess Than 1,000 Sq. Ft.; ❑ More Than 1,000 Sq.-Ft, <br /> rj <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> II I hereby certify that I have prepared this application and,that the work will be!done in.accordanc2-4i� J I ty <br /> ordinapces, state laws, and-rules-and gulation -of-the-San-doaquin-Local-Health District. <br /> APPLICANT'S SIGNATURE XE <br /> FOR DEPARTMENT USE ONLY ; <br /> I Fee Is Due: ❑-ANNUALLY ❑ PER UNIT l ❑ PER'SITE---�_.❑ EAC j -,.❑ January 1 &RaceWed By January 31 ❑ July 1 &Received By July 31 <br /> a �} REMIT <br /> BASE EXPLANATION 't> KILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE 'S ,SATE �OREhAITTED�**"R 'aa AMOUNT 4 <br /> FEE ��� ( !F` A• Y qtr I <br /> LESS t �! <br /> t PRORATION <br /> PLUS ,g <br /> PENALTY <br /> OTHER. <br /> OTHER, J <br /> Received bykUV71 Receipt No, Permit No. IsAuance Qfate - Mailed pe{ �� <br /> -:APPLICANT—RETURN ALL COPIES T,O: "ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2909 �STO 011 GAS '- <br />