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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 /> y Business Name(DBA)'VIA --- f,� 5GQ s �� ZNC" Address ZEDS '+� –.� STL��LJ, <br /> z Owner Address <br /> d <br /> I S2 Firm Partners, Addresses and Telephone Numbers - <br /> r a Business Telephone No. 4��ili,- Emergency Telephone No. <br /> d <br /> j Contractor Licence No. <br /> I Applicants Name (Print) �� �� �+ Title QST Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> M 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30, 19 Disposal Sites – <br /> I Description(Make/Yr., Color) <br /> 1 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 �V <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 /> Testt Lo ation Test Date/Time <br /> 4. I� SANITATION PERMIT <br /> � S!C' <br /> Job Addres /Location—«.--•�:�®• W y <br /> OwnerL Address <br /> ,� /d!! <br /> ❑ SEPTIC TANK ❑ CESSPOOL 2 LEACHING FIELD L3 SEEPAGE PIT ❑ PACKAGE PLANT <br /> 2 PERMANENT ❑ TEMPORARY ❑ NEW ©'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) <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 Thari 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 5 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> : F <br /> I hereby certify that I have prepared this application that the work will be done in accordance with San Joaquin C unty <br /> ordinances, stat r a regul ns of Sa oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r <br /> ' FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 Rec ved By January 31 ❑ July 1 &Received By July 31 <br /> I BILLING REMITT CE $ ;F REMIT <br /> � BASE - EXPLANATION DATE DAT REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> 4 FEE SYS <br /> LESS }� <br /> PRORATION I <br /> PLUS <br /> PENALTY <br /> OTHER �r - <br /> _ OTHER <br /> p Received by Date Receipt No. Permit No, - Issuance Date Mailedeliver - <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES ,. 1601 E.HAZELTON AVE.,P.O.Box 2004 STOCK ON,CA 9 201 , <br />