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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 4 <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE I <br /> t LIQUID WASTE t <br /> Application is ereby made t carry on b siness int a juris ictional area of the San Joaquin Local Health Distric <br /> NBusiness Name BA) Address ®&i 614- 7 E 7 <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbe_ <br /> a. Business Telephone No. ✓�� , Emergency Telephone No. <br /> Contractor Licence No. 2— <br /> L Applicants Name (Print) 7 Title 424.� Date <br /> Please check Applicable Category (1-7)and Fill in the Requireg Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites i <br /> Description(Make/Yr., Color) \=i <br /> Serial No. CAL. License No. CAL. Liccase 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 L cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location Z3 7 <br /> O,nr r1 �i� Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ BEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR a OTHER5.tVO <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> I <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified I <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. j <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ' <br /> I <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 r and Regula ' ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY l <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Recelved By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE PATE REMITTED AMOUNT DUE CHECKED <br /> it AMOUNT <br /> FEE - r <br /> 4 <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _ l <br /> -7 ---1-17 � <br /> Received by Date Receipt No. - - Permit No. Issuance Date Mailed Delivered. l <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH P€RMITISERVICES r, 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO CA 5201 ; <br /> •ala - "�'7 �'jr-�-�_ -���. �'2 % ' <br />