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Applications Will Be Processed When Submitted Properly-Completed.Be Sure To SignTheApplication. <br /> APPLICATION <br /> (For Non-TransferE!ble,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> '7`--A:0C.E—z- V LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> = . <br /> Business Name (DBA) Address 60 6-"X I*1 rn c 7791 <br /> aOwner Address <br /> U Firm Partners,.Addresses and Telephone Numbers <br /> aBusiness Telephone No — A- 7 Emergency Telephone No. t <br /> Contractor Licence No. 3 <br /> LApplicants Name (Print) F�-aY� 1,0ao� Title �5r"I�A'�� Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) s <br /> r <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) I <br /> Serial No. CAL. License No. CAL. Licc,se Renewal No. <br /> Capacity Gal.,Weights &Measures No. r <br /> Equipment Parking Address ' <br /> 2. ❑ PUMPER YARD CJo <br /> For July 1, • June 30, 19 ' <br /> No. of Vehicles Stored r <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 /> Tes Location Test Date/Time { <br /> 4. SANITATION PERMIT <br /> Job Address/L � <br /> ocationT' m' <br /> f <br /> Owner `� /+ N Address W O A9 PE2.5',611M-erg S7"vCA7-47-) <br /> , {SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT x <br /> Jy PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER suv-, �• <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> i; <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 f <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> a <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. t <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, state laws, and rules and regulatio he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X Cl - <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 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY k -- <br /> OTHER <br /> OTHER <br /> Received by - Date Receipt No. Permit No. Is uance ate Mailed Deliv red J 7 <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES� - 1601 E.HAZE_LTON AVE,,P.O.P. /B000xxx 22000D9`/f STO�F/ON,N,CA95201 '=F <br />