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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> i (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Or Business Name (20A) d ess + <br /> $ Al dd ress A <br /> z OwnerZmzazep� <br /> u Firm Partners, Addresses and Telephone Numbers Z p0119 <br /> Q. Business Telephone No. ' Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title —_�� Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. 13 R.UMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30, 19 1! Disposal Sites <br /> Description(Make/Yr., Color) 1 <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored 1M. <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST i <br /> E. No.C <br /> or R <br /> R.S. . . <br /> R.S. or R.C.E. Name , <br /> Tesocation ISI Test Date/Time <br /> I <br /> 4. SANITATION PERMI <br /> Job Address/L anon <br /> Owner 4 Address PI" <br /> 09 SEPTIC TANK CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT TI <br /> D PERMANENT ❑ TEMPORIARY 11 NEW .REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For Ir my 1, -June 30, 19 <br /> Type Construction 111. Disposal Site <br /> No. of Units 111 _ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br />� Operator Name :I` <br /> Plant Location I <br /> Plant Capacity �M No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> i SIZE: ❑ Less Than 1,000 Sq. Vit., ❑ More Than 1,000 Sq. Ft. <br /> 11 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> li <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state 1aws;;�a d rules and Iationthe San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X — <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ! ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received <br /> R MlTuly 31 <br /> BILLING REM ITT CE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE D TE REMITTED AMOUNT <br /> FEE iglf� /V <br /> y Ll <br /> LESS II <br /> PRORATION I <br /> PLUS <br /> _ PENALTY II <br /> OTHER <br /> OTHER <br /> 7T �c 7 <br /> Receipt No. Permit No, Issuance Date Mailed Delivered <br /> Received by ate <br /> ,M. <br /> j APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON A+—VE„ .O�Bov 2009 STOGKTON,CA <br /> e YL <br />