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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Ile APPLICATION a <br /> 4 = (For Non-Transierable, Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin LI Health District a <br /> Business Name (DBA) • Al I S o Address R A- <br /> I { <br /> z OwnerOK9�- Address f <br /> a <br /> J Firm Partners,Addresses and Telephone Numbers - <br /> a9Business Telephone Na �li�'1 40 Emergency Telephone No. <br /> Contractor Licence No.- 9 7CI 7 3. - N <br /> Applicants Name (Print) "w it Title Neer Date --f " <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> 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 /> 1 2. 11 PUMPER YARD � <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. Na. t �� <br /> I Test Date/Time <br /> Test Location <br /> 4. .9 SANITATION PERMIT <br /> Job AddresslLocation A ��� 4A <br /> OwnerIL� FRtAJ1� Address air i'f� ti1. 14 ��C►`A, <br /> SEPTIC TANK ❑ CESSPOOL ;-6LLEACHING FIELD ElSEEPAGE PIT PACKAGE PLAN <br /> PERMANENT 0 TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 N <br /> Type Construction Disposal Site n <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> I 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. -C3 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 /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, nd ules nd regulations f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r ' <br /> I <br /> F <br /> 1ORD PARTMENT USE ONLY - <br /> F Fee Is Due: ❑ ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> S REWT <br /> -BASE EXPLANATION BILLING _ REMITTANCE $ AMOUNT DUE CHECKED -. <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS r - d <br /> PENALTY <br /> OTHER- <br /> OTHER w ` ' <br /> -7 Ll <br /> t"' ,, - Received by liate Receipt No. - Permit No. lssuan&Date Mailed Delivered <br /> ,- APPLICANT—RETURN ALL COME TO: ENVIRONMENTAL HEALTH PERMITISERVICES _ 1601 E.HAZELTDN AVE.,P.O.Box 2004 STOGI(TDN;CA 9520 <br />