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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 11!,07 <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE r <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> UF) (DBA) e6CM/�'��ii w LE Address z�� <br /> �, Business Name DBA �s�� a <br /> aOwner-IM Address 7-- <br /> :u Firm Partners, Addresses and Tele0one Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. ` <br /> L Applicants Name (Print) e- /11 ���//T Title AF5r, Date &2! <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. Liccnse 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. or R.C.E. Name R.S. or R.C.E. No. <br /> Test ocation Test Date/Time <br /> 4. SANITATION PERMIT �p�/'�/ <br /> Job Address/Location /7r` AeA <br /> Owner 0 Z Z Wo Address .33.Z <br /> K SEPTIC TANK ❑ CESSPOOL LEACHING FIELD OSEEPAGE PIT ❑ PACKAGE PLANT ' <br /> )C 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 <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 that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an a nd regulation of the Sa J aquin Local Health District. <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> r rj <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER (/J' <br /> • O✓h <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Defiv <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON.AVE.,P.O.Box 2009 STOC O A 20 <br />