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l -10algn IIII►err• <br /> Applications Will Be Processed When Submitted Property Comp_ <br /> eted.BeSure <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL <br /> WASTE <br /> HEALTH <br /> PERMIT <br /> LIQUID <br /> p,v , t3vir t o /vl oe/c�s T o <br /> Application is hereby made to carryon bu�ne�on the jurisdictionalAddress <br /> ad essthe San Joaquin Local Health District <br /> Business Name (DBA) Address <br /> a Owner <br /> h o <br /> j Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> �.�3- <br /> a, Business Telephone No_ /6 6 - <br /> Contractor Licence No. Title Date. <br /> L Applicants Name (Print) p� <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, <br /> June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License No. CAL. License Renewal No. <br /> ` <br /> Serial No. <br /> t Capacity <br /> 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 R.S. or R.G.E.No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4, Ir SANITATION PERMITSC�y <br /> /69.ZG �scAGoerf 1.�e�G.aT.9 �i <br /> Job Address/Location Address Sigi+� <br /> Owner LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT Q <br /> {�SEPTIC TANK C1 CESSPOOL C1 REPAIR <br /> ® OTHER <br /> ❑ PERMANENT El TEMPORARY C1 NEW Q" <br /> 5. 13 CHEMICAL TOILETS For July 1, -June 30, 19 d <br /> Disposal Site <br /> Type Construction <br /> Equipment Storage/Cleaning Locations) <br /> No. of Units <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> b Plant Capacity C <br /> T. ❑ LAUNDRY For July 1,=June 30,19More Than 1,400 Sq. Ft. T <br /> SIZE: C3 Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. t <br /> j <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> k: ordinances, state laws, and rule and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> PER UNIT [:I EACH - 11 January i &Received ey January 31 ❑ Su4y 1 &Received By July 31 <br /> PER SITE <br /> Fee IS Due: ❑ ANNUALLY ❑ REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i OTHER <br /> OTHER <br /> � Permit No. I suanc Date Mailed De rver <br /> Received by Date - Receipt No. -GA 20t—y <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 7601 E.HAZELTON AVE.,.P.O.Box 2099. STDG ON, <br />