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Application Vill Be Processed When Submitted ProperlyCamplereapfl� <br /> APPLICATION <br /> (Far Nan-Transferable,Revocable,and Sus endable) SEPTAGE <br /> ENVIRONMENTALATH PERMIT <br /> LIQUID <br /> YY <br /> A04;71 <br /> Applic ti by m o Clan %otr b ess in the jurisdictional area of the S n Joa Lo He h tr <br /> Addre <br /> NBusiness Nar D A) Address <br /> z Owner <br /> a <br /> Firm Partners, ddresses and Telephon tJ�umbe t Emergency Telephone No. <br /> M Business Telephone No. <br /> apa <br /> te <br /> Contractor Licence No. Title o� <br /> LApplicants Name (Print) V <br /> Please check Applicable Category (1-7) and Fill in the Required Inf rmation Q <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FORaACs Sites For July 1,_ June 30, 19 <br /> Description(Make/Yr., Color) CAL License No. CAL. License Renewal No. <br /> Serial 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 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name Te t,Date/ ime <br /> Test Location , ` <br /> 4. 19r SANITATION PERMIT <br /> Job Addr s/ oo tion E 0 <br /> Address <br /> Owner ❑ PACKAGE PLANT <br /> ❑ SEPTI(' TANK CESSPOOL LEACHING FIELD `SEEPAGE PIT ❑ OTHER <br /> 'PERMANENT <br /> ❑ TEMPORARY ❑ NEW ;FrREPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, ipisposal Site <br /> Type Construction iP <br /> No. of Units Equipment Storage/Cleaning Location(s) 0 <br /> 6. 13PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> Than 1,000 Sq. Ft. <br /> SIZE: 11 Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. <br /> I hereby certify that I have pre this application and that a work w'11 be done in accordance with San Joaquin County <br /> ordinances, state laws, and r regulations of a San J uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> F <br /> ee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE [j EACH ❑ January 1 &Received By 3anuary 31 ❑ July 1 &Receivend By July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION HATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION /I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER /j,� <br /> 047;��o 6 rad 'SO ./ <br /> Date Receipt No _ <br /> Permit No. Issuance Date Mailed De ivere <br /> Received by1601 E.HAZELTON AVE.,P.O.Box 2009 570C ON,CA 95 0 <br /> — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />