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4 Applicatioris Will Be Processed When Submitted Properly Completed. BeSureTo SignTneAppncauon. <br /> f ;APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic ' n is hereby m e to arry on bus e s in t jurisdictional area of theAan Joa in Local Health Distn t <br /> rn Busine ame (DB 4f: Address " <br /> i Owne Address , <br /> a _ fi <br /> ,Firm Partners, Addresses and T�ephone tubers �] <br /> ` a Business Telephone No. [ Emergency Telephone No. <br /> a Z Z <br /> i Contractor Licence No. l I <br /> L Applicants Name (Print) ` <br /> Title 0 Date <br /> Please check Applicable Ca ory (1-7)and Fill in th Required Information <br /> 1. ❑ PUMPER VEHICLE RM I! -REGISTRATION (FOR EACH VEHICLE) <br /> For July .•`Jun e 30,19�r Disposal Sites <br /> D riptiori(MakeNr., Color)_ � <br /> Serial No. - CAL. License No. CAL. License Renewal No. <br /> l Capacity ' � Gal., Weights &Measures No. f <br /> F Equipment Parking Address �� 1 <br /> 2. ❑ PUMPER YARD I �. <br /> For July 1, June 30, 19 f <br /> No. of Vehicles Stored �M <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST I - <br /> R.S. or R.G.E. Name R.S.or R.C.E. No. <br /> Test <br /> �,Lotion I! Test Date/Time <br /> If <br /> 4. L7 SANITATION PERMIT I�, Ill, JIL111.111kJ9, <br /> Job Addre /Location 1, <br /> Owner dress M <br /> I, ❑ LEACHING FIELD -',LfSEEPAGE-PIT 13 PACKAGE PLANT [ _, <br /> ❑ SEPTIC TANK`_ CESSPOOL <br /> Ul PERMANENT 4_; ❑ TEMPORARY ❑ NEW REPAIR f 11 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction <br /> Disposal-Site <br /> No. of Units 1F_- -�Equipgent Storage/Cleaning-Location(s)';. <br /> 6. 13LANT c PACKAGE TREATMENTiPFor July 1.-•June 30, 19 <br /> Where Certified <br /> Operator Name I� <br /> Plant Location �* <br /> No. Units Served <br /> Plant Capacity a` k <br /> 7. ❑ LAUNDRY For July t; ilrJune 30;'19 <br /> SIZE: ❑ Less Than 1,000,S Ft., ❑ More Than 1,000 Sq. Ft. , <br /> ❑ l]RY CLEANING,Cherrlicals.Used/Amount/Mo. <br /> i I hereby certify th I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a d rules and gul tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X .� <br /> e' Q FOR DEPARTMENT USE ONLY <br /> --z q <br /> t Fee 1s Due: ❑ ANNUALLY; - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> ill - BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> ! 4 <br /> FEE 4 <br /> LESS <br /> PRORATION - <br /> PLUS II <br /> PENALTY <br /> I' I <br /> OTHER; I!' <br /> OTHER <br /> IS 13 Y <br /> Received by Date Receipt No. Permit No Issuanceluate, Mailed Delivered- <br /> APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.'RAZELTON AV :gax 2009 ST1]CKT Cf;85201 <br /> n1l — `1/f.`�Yz/� 14 11.8x: - _ <br />