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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION I5 0,-2-0 <br /> � r <br /> ° (For Non-Transferable, Revocable,and Suspendable) 6b <br /> ENVIRONMENTAL. HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati I herby m de to car busi less i the I dictional area of the S Joaq Wn Local Health Dis ' <br /> ,Business Name (D ) r 4'�~ Address es <br /> z Owner ddress --�-• <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. . fog s— Emergency Telephone No. <br /> Contractor Licence No. �- <br /> L Applicants Name (Print) 61W — Title rQ1 Date <br /> Please check Applicable Category (1-7) and Fill in the Requ ed Information I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (F%R EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. Lice.se 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 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S./orR '.E. Name R.S. or R.C.E. No. <br /> on Test Date/Time <br /> ITATION PERMIT <br /> Job Address/Location <br /> Owner Address xj <br /> ❑ SEPTIC TANK ❑ C SPOOL OLEACHING FIELD T ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW IVREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 <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. rt. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accqrnce with San Joaquin County <br /> ordinances, state laws, and rul nd regulations an oaquin Local Health District. ' <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USELYS <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ uz &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING R T ANCE $ REMIT <br /> BASE EXPLANATION DATE •ATE REMITTED AMOUNT DUE CHECKED <br /> r AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ,¢ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER (� <br /> V 1 <br /> Received by Date 'Receipt No. Permit No lssij4fice Datel Mailed 00verely <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.O.Box 2909 STOCKT N,CA 9 61 <br />