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Applications Will Be Processed-When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ,. (For Non-Transferable, Revocable;and Suspendable) SEPTAGE <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 /> Business Name (DBA) -S1,d Address <br /> J. <br /> z Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business'Telephone No. G, �� Emergency Telephone No. 1 <br /> Contractor Licence No. <br /> �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) f� <br /> For July 1, - June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No.— <br /> Capacity <br /> o. .Capacity Gal., Weights &Measures No. <I <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 ` t <br /> No. of Vehicles Stored r <br /> No. of Chemical Toilets Stored <br /> 3. '❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location ~ ` Test Date/Time <br /> 4. 0 SANITATION PERMIT- <br /> Job <br /> ERMITJob Address/Location -5 L `;0 Lo 0 e p <br /> Owner 7Z: S /r dfg!95+ Address <br /> SEPTIC TANK ❑ CESSPOOL— ,W,{ LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT 11 TEMPORARY ,�1 NEW ❑ REPAIR ❑ OTHER r <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 d <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 U5 <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 /> Y <br /> tiro 6 f <br /> 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X I <br /> FOR DEPARTMENT USE ONLY - <br /> Fee Is Due: ❑ AN ❑-PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January.31(• © July 1 &Received By July 31 <br /> - REMIT <br /> f BILLING REMITTANCE '$ r - <br /> �,k <br /> BASE EXPLANATION AMOUNT DUE" CHECKED <br /> w <br /> DATE+ DATE REMITTED 'y i AMOUNT <br /> FEE �. <br /> LESS <br /> PRORATION <br /> PLUS f <br /> PENALTY." • - - _ <br /> .. OTHER % <br /> s OTHER <br /> Received byDate t Receipt No. Permit No. Is uance�DteFE., <br /> Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH Date <br /> 1601 E.HAZELTON AP.O.Boil 2009 STOCKT ON,CA 95201 <br />