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¢ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION -� <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE t <br /> f ry � LIQUID WASTE <br /> Application is h reby ade to car ry on bus' ess in the jurisdictional area of the San Joa uin Local Health District � G <br /> F Business Name (DBA) �e4//'!SA 1.4 Address i / <br /> z Owner Address <br /> a <br /> 7 Firm Partners, Addresses and Telephone Pqumbers <br /> aBusiness Telephone No. 4//�w 9"� Emergency Telephone No. <br /> Contractor Licence No. 9s 3 <br /> L Applicants Name (Print) Title a27M/9 7&- Date 2�-,2y <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 y J <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. 1 <br /> Test Location Test Date/Time <br /> 4. X SANITATION PERMIT n <br /> Job Address/Location /�� S- J -4/ <br /> Owner C� ! ,mr Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> IN PERMANENT ❑ TEMPORARY ❑ NEW 09 REPAIR ❑ OTHER <br /> 5. ❑ 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, and rules and regul tionsofoff the San Joaquin Local Health District. <br /> APPLICANT'SSIGNATUREX -^l1y► Q27��1,L <br /> FOR DEPARTMENT USE ON#j <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT [K PER SITE ❑ EACH ❑ Ja ar 1 4Aeceived By January 31 ❑ July 1 &Received By July 31 <br /> BILLING EMITTAN $ REMIT AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DA REMITTED <br /> AMOUNT <br /> FEE t/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> —1 o '7 fo <br /> Received by Date Receipt No. Permit No. I suance ate Mailed llelivelcl <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,CA 5 <br />