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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ^i <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) 1 <br /> " s } ENVIRONMENTAL HEALTH PERMIT SEPTAGE � <br /> LIQUID WASTE • <br /> Apphcat' is hereby do to carry on business in the jurisdictional area of theSanJoaquin Local H I District <br /> F Business Name (DBA) <br /> OQ _Address <br /> aOwner_ /�+r _ Address Q5 54 4'54 6 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants'Name•(Print} .!' C. Title 46,17 Date 7--1/-77 <br /> Please cFieck}Applicable Categbry (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_R.Measur-es No.. _ _ (0 II r <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored I�A <br /> No. of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST r <br /> R.S. or R.C.E. Name of R.S. or R.C.E. No. F.. <br /> Test Location ''� Test Date/Time �- <br /> 4. J4 SANITATION PERMI <br /> Job Address/Location ' e-1 UEl�Qt, E f- <br /> Owner/-4prs/10e &(1410",1 Address <br /> SEPTIC TANK ❑ CESSPOOL I X LEACHING FIEL'D.'s J9 SEEPAGE PIT ❑ PACKAGE PLANT' <br /> PERMANENT E] TEMPORARY I )KNEW El REPAIR ❑.OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -- 1 <br /> Type Construction ! �,-Dispo al Site ' <br /> No. of Units Equipment Storage,Clean,ing Location(s) # <br /> 6. ❑ PACKAGE TREATMENT�PLANT For July 1, -June 30; 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity ( O No. Units 5e ery d <br /> 7. ❑ LAUNDRY For July 1, -.June 30,19 j <br /> SIZE: ElLess Than 1,000 Sq. Ft., ® More Than 1,000 Sq. Ft. # a <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 1 <br /> ti Y <br /> I hereby certify that have prepared this application and that the:work will-be done in accordance with San Joaquin Count <br /> ordinances, state laws, an les and regulations ofa Sari Joagii n�Local Health District. <br /> APPLICANT'S SIGNATURE X f nom* + <br /> s <br /> ( FOR DEPARTMENT USE ONLY . <br /> Fee Is Due: ❑ ANNUALLY i ❑ PERIUNIT PER SITE ❑ EACH 0 January 1 &Received By January 31 _❑-July 1 &Received By July 31 } <br /> • { BILLING REMITTANCE - $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED _ <br /> DATE pAT� REMITTED t T AMOUN <br /> s / <br /> FEE <br /> LESS <br /> PRORATIONPLUS <br /> t <br /> PENALTY <br /> OTHERF ,y <br /> OTHER f t:Z,t .� <br /> _ <br /> Received by Date _ F. Receipt No ermit No'. _ IstuancOf Date Mailed 4Delived-APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009ON,CA 95201 <br />