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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> k Appl ication is by lade to c rry OD bu_si n theilurisoicnnal area of the Sa ,ogaqui Local Health District <br /> rn Business Name (D A) Address67 =�3.�._...__ <br /> i Owner Address ''- ---�— <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers . <br /> t a Business Telephone No. . 31/9 0/a-5- Emergency Telephone No. �1 <br /> Contractor Licence No. Li <br /> LApplicants Name (Print) - Title Date `j r;7 � I } <br /> Please check Applicable Category (1-7)and Fill in the Required I ntoFn,tion 1 <br /> 1. .❑,PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 1 Disposal Sites <br /> Description(Make'/Yr 3COIOr) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity � � Gal., Weights &Measures No. f <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD Ll <br /> For July I, June 30, 19 _, <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST r ( � <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. # j <br /> Test�LoSAtion t Test Date/Time <br /> 4. L� NITATION PERMIT ?{ tw rr <br /> Job Address/Lq9ation4 <br /> Ow r Yom""' Address 4 —K- ; <br /> u� TIC TANK ❑ CESSPOOL ^CHING FIELD SEEPAGE PIT ❑;PACAGE'PLANT <br /> L-1'PERMANENT ❑ TEMPORARY L1 NEW ❑ REPAIR ❑ OTHERS <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ""` <br /> Type Construction Disposal Site t <br /> k No.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Where Certified. v <br /> Plant Location s -- <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. J <br /> a <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San JoCounty <br /> ordinances, state laws, and ruI d regulati s he San Joaquin Local Health District. r �� UU <br /> i <br /> APPLICANT'S SIGNATURE X _ '1/j <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received Jan a y 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE <br /> . BASE EXPLANATION DATE DATE REA1 AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ` S C9 <br /> LESS le <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date 1 Receipt No. Permit No. Issutince Dale Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> f <br />