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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 /> F LIQUID WASTE <br /> Application is areby made to carryon business in the jurisdictional area of the San as ocaI Health District <br /> HBusiness Nam DBA) Address `R X 7 7 <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbe <br /> K Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date �7 <br /> Please check Applicable Category (1-7)and Fill in the Required Infor anon <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites I; <br /> Description(Make/Yr., Color) <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 /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST w <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test LL tion Test Date/Time <br /> 4. t� SANITATION PERMIT <br /> Job Address/ kion _ <br /> Owner Address 2ki —0c <br /> ❑ SEPTIC K ❑ CESSPOOL LEACHING FIELD ❑ SS SAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMA NT ❑ TEMPORARY ❑ NEW 0 REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) -"(D <br /> 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., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Monte owner orlicerseda e.rzs 1'oporfcrmanceofthevvwkfcrwhichthispermitisissued,lshallnote€nployanyperson <br /> ISE such manner as to bec l};'S L 'k Epinr Pn, 1 ;t iAws a#0nilipr�.:a." 1 <br /> anzrae,er's hlemq pr sUc 1 a,,dd - e ;'_ :a.iQwrirta "'I cartl'y that in the performance of the work for which this permit is issued,I shall <br /> � rjcy Io2Ye yicertify`that }I'flaverprepareo`Wis ap!11c Pion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and regulations of 1119 San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �. f}, [J AMOUNT <br /> FEE LI'C; LJ,.V 's �1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.O.So 2009 ST�OCKyY N CA 95201 <br /> KQ . 61. LYa l uj. � t� <br />