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`_Applications Will Be Processed When Submitted Properly Completed. Be Sure-To Sign The Application. <br /> 3 L 3 li APPLICATION <br /> (For 2 Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is,Ffereby made to ar ..busin ss in the jurisdi ional area of the Sa Joaqi Local Health District <br /> HBusiness Name (D A) Z_c Address <br /> j a Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 5' Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date _!$e647 <br /> Please'chdck Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, }' Uune 30, 19Disposal Sites <br /> Description,(M_a_ke_/Yri Color) <br /> Serial No. n- ( CAL. License No. CAL. License Renewal No. <br /> Ca aci't� Weights &Measures No. <br /> P y <br /> Equipment P6 ii Address <br /> 2. ❑ PUMPER YARD .a <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.C.E. Name R.S.or R.C.E. No. <br /> Test L aeon <br /> Test Date/Time <br /> 4. SANITATION PERMIT �7 r� �10� <br /> i Job Address/Location _ ^' <br /> { Cr <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESS OL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> C] PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 6 a <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> t Type Construction 1 Disposal Site <br /> r No. of Units Equipment Storage/Cleaning Location(s) I <br /> 6. ❑ PACKAGE TREATMENT,PLANT For€July 1, -June 30, 19 <br /> Operator Name a Where,Certifil <br /> Plant Location ) / 4 <br /> Plant Capacity No. Units Served / <br /> 7. ❑ LAUNDRY For July 1''�fJune 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft,, ❑.More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. I f <br /> I hereby certify that l`Yiave prepared this application and`lhat the work will be done in`accaf is ice with San Joaquin County <br /> 16.__11A <br /> ordinances, state laws, and rut and regulations of the San Joaquin Local Health Distric . <br /> APPLICANT'S SIGNATURE X <br /> VIC <br /> . - <br /> E.,� <br /> - FOR DEPARTMENT 5E O Y <br /> Fee is DUB: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH A,I nuary 1 &Received By January 31 ❑ July 1 8 Received.By July 31 <br /> REMIT <br /> BASE EXPLANATI N KILLING TANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I! <br /> PENALTY <br /> OTHER <br /> OTHER <br /> o S fog 5 `? 6 ` <br /> Received by Dale ceii No. Permit No 1 suan a Date Mailed live d <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES „ -� 1601'FSHI�L�l}VE.,P.O.Box 21)09 STO TON,CA 95201 <br />