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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 3 <br /> 3 (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEpTAGE <br /> LIQUID WASTE <br /> Application ' h rpby made to ca on b s'ness in the jurisdictional area of the San J a uin Lo I He h District n <br /> y Business Name (DB ) � I-S Address �2 is it yll- <br /> z Owner S'rU:C C s a Address f , <br /> Firm Partners, Addresses and Telephone Numbers �_ 7 <br /> IL Business Telephone NO. Emergency Telephone No. t <br /> Contractor Licence No. s1 — <br /> Applicants Name (Print) - Title _/-1 6C r Date l Q~/ <br /> Please check Applicable Category(1-7) and Fill in the e u red nfo at on <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,_ June 30, 19 Disposal Sites _J <br /> Description(Make/Yr., Color) <br /> Serial No. _ CAL. License No. CAL. License Renewal No. Cr <br /> Capacity Gal.,Weights & Measures No. �I <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD M <br /> For July 1,_ June 30, 19 <br /> No. of Vehicles Stored <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 /> Test Location Test Date/Time <br /> 4. 9 SANITATION PERMIT � <br /> Job Address/Location b <br /> caner (/ e�' Address <br /> SEPTIC TANK © CESSPOOL 0 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER _SjJ YyN <br /> 5. 1] 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 Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared thi ppiication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and re latiqps of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT 1kPER SITE ❑ EACH ❑ Januar &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING RE T CE $ REMIT <br /> BASE EXPLANATION RATE TE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> .sg 1l0 10 � <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed �1)re_livefed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STO T 201 <br />