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Applications Will Be Processed When'Sutimitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> \ (For Non-Transferable, Revocable,and Suspendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional area of the San Joaqui, cal H Ith)District `/,� <br /> FBusiness Name (DBA) - Address "& rl � /�/wgo, 'I d_�_M <br /> C Owner ✓j'L le �S � V"P - Add ess <br /> Firm Partners, Addresses aTel hon l,umb s ,. <br /> aBusiness Telephone No. Emergency T lephone No. <br /> Contractor Licence No. ;1 <br /> L Applicants Name (Print) - a Title 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 Gal.,Weights&Measures No. 00 <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. or R.C.E. Name R.S. or R.C.E.No. <br /> Test�LLoc��ation Test Date/Time <br /> `f <br /> 4. 'SANITATION PERMIT I <br /> Job Addres /Location /t ® /`f Oil/ <br /> Owner Addres r? <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ 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 �1 <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. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify tha 1 ha a Bred tis ap6ns <br /> on and that the work will be done in accordance=with San Joaquin County <br /> ordinances;state la a d r 1 s and r ulatithe San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee 1s 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 AM UNT DUE CHECKED <br /> AMOU <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHERA6 A <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Deiive7fd <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH'PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOcifrON,CA 9 201 <br />