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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,, 11 APPLICATION <br /> r >-1 (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i ereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Dist t <br /> w Business Name (DBA) r Address /1ee�2+-7� 7 <br /> i Owner - Address <br /> a - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. -1 Emergency Telephone No. <br /> Contractor Licence No. 7--2--6 <br /> Applicants Name (Print) 4 'zu Title Date pBi — <br /> Please check Applicable Category(1-7) and Fill in the Requirild 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. <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 /> Testi cation Test Date/Time N <br /> 4. SANITATION PERMIT <br /> Job Address/L lon 2 Q ( Ee � <br /> Owner Address / ice f 4 <br /> G5V EPTIC TANK E] CESSPOOL ,®,LEACHING FIELD SEEPAGE PIT El PACKAGE PLANT <br /> (� PERMANENT ❑ TEMPORARY E NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 Y' <br /> Type Construction Disposal Site S <br /> No. of Units Equipment Storage/Cleaning Location(s) (/1 <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, and rules and gulationss of th Joaquin Local Health Di trict. <br /> APPLICANT'S SIGNATURE X 2 y� <br /> "1 <br /> FOR DEPARTMENT Uf <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH 1:11"! nuwy 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING E I TANCE $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER y <br /> OTHER n <br /> 53S(� OL <br /> Received by Date Receipt No. Permit No. Idsuande Date Mailed eliv d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 k.HAZELTON AVE. P.O.Box 2009 STO TON,CA 95201 <br />