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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> 10 ENVIRONMENTAL HEALTH PERMIT <br /> �I Y LIQUID WASTE <br /> Application i's he by made to car on business in the jurisdictional area of th�p San Joaquin Local Health Distr'ct <br /> rn Business Name (DBA)�_ /�ri�K.��CJ+G. Addres5/`Q '!7�"� �SzO <br /> z Owner Address <br /> C <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. 71 <br /> Contractor Licence No. S <br /> 4 = Date <br /> L Applicants Name (Print) Title <br /> Please check Applicable Category(1-7)a d Fill in the Required Information r� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites X" <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 /> Test Loc . Test Date/Time <br /> 4. SANITATION PERMIT e /� Jf,� <br /> Job Address/Location 1�f3�7 1 4577A) �y` c'ra��,�� UJ <br /> Owner �,#• ��'1•'�� ,,7� Address artr� -•7 <br /> 0-SEPTIC TANK 11 CESSPOOL L'LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 0 PERMANENT ❑ TEMPORARY © NEW 2—R'EPA I R ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site .5' <br /> No. of Units Equipment Storage/Cleaning Location(s) Z <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 h ve prepared this applica ' n and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws rules a egulatio f the S aqu' Local Health District. <br /> APPLICANT'S SIGNATURE / <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT K3 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. t Issuan a Date Mailed De iver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON,CA 95201 <br />