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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r \ (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> ✓N LIQUID WASTE <br /> Application-is hereby de t carry o business in the jurisdictional area of the San Joaquin ocal HIea th rict <br /> HBusiness ame (D ) Addr s 'Pa <br /> aOwner Address <br /> Firm Partners, Addresses an le hon N m rs <br /> aBusiness Telephone No. S 04l Emergency Telephone No. <br /> Contractor Licence No. �c _ <br /> L Applicants Name (Print) l fw r Title QST Date , <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER_ VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <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 EE Lal., WeightEN&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored f <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST f` <br /> R.S. or R.C.E. Name i R.S. or R.C.E. No. <br /> Test LocationTest Date/Time <br /> 4. VSANITATION PERMIT ,_ r <br /> Job Address/Location - <br /> Owner Address <br /> SEPTIC TAN ❑ CESSPOOL LEACHING FIELD; X SEEPAGE PIT POGKAGE PLANT <br /> PERMANENT ❑ TEMPORARY KNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TgILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleanini Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June,3 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity ~' # ;N9.Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 1,9 - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. _ <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 accordance with San Joaquin County <br /> ordinances, state laws, iuland re lations the San Joaquin Local Health District. <br /> � <br /> APPLICANT'S SIGNATURE X � `'`� _ . <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 F2 <br /> 7 <br /> Received by Date Receipt No. Permit No. is an a Date Mailedeli red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 ST CKTON',CA95201 <br />