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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> xT <br /> APPLICATION <br /> , - (For Non-Transferable, Revocable, and Suspendable) 5EPTAGE <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 /> NBusinessa (DBA) Address <br /> aOwner -✓; Gy' Address 4-P— <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. - Emergency Telephone No. <br /> Contractor Licence No. _ <br /> L Applicants Name (Print) Title Date <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 f <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. I <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 <br /> No. of Chemical Toilets-Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> t11SANITATION PERMIT 7 i—9t <br /> Address/Location � 1 r— <br /> O ner Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> y <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 f <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 /> Gtl10 <br /> iW' San <br /> 4J <br /> I hereby certify that I have prepared�his work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru and n 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 By July 31 A <br /> BILLING REMITTANCE - $ REMIT <br /> BASE - EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER - -- �- <br /> ✓i <br /> �ivedby �»�Date -Receipt No k.^ - Permit""o Issuance Date-' Mailed Delivered <br /> AP�1tf.N7±RETVRN=AL'LCOPIE WRONMENTAL HEALTH PERMlT/SERYI 5 " '' . 1601 E:HAZELTON AVE.,P.O.boa 2009 5TOCK70N,CA 95201 <br />