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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) ^SEPTAGE <br /> es ENVIRONMENTAL. HEALTH PERMIT <br /> - ^` •� LIQUID WASTE <br /> Application ' here y e to carry o busin in the juri Ictional area of the Spn Joa uin Local Health Dis I t <br /> ,F Business Name (DBA)_ c � Address . � <br /> i OwrierAddress <br /> a y <br /> Firm Partners, Addresses and Telephone Nu bers <br /> a Business Telephone No L& Emergency Telephone No. <br /> 14i 4�1. <br /> a <br /> Contractor Licence No. <br /> e� 1 <br /> t L Applicants Name (Print, ; l0 0 Title - 5 Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTIIRATION (FOR EACH VEHICLE) <br /> For July f, mm June 30, 19 if Disposal Sites <br /> Description(Make/Yr., Color) <br /> I Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., eights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, - June 30, 19 ` f , <br /> No. of Vehicles Stored ` <br /> No..of Chemical Toilets Stored <br /> i° 3. ❑ PERCOLATION TEST f <br /> R.S. or R.C.E. Name. �f R.S. or R.C.E. No. <br /> Tesocation Test Date/Time <br /> t <br /> 4. �SANITATION PERMIT �.. <br /> Job Address! cat75Aion <br /> Owner Address W <br /> ❑ SEPTIC TANK ❑ CESSPOOL ,I�LEACHING FIELD ❑ SEEPAGE PIT ❑ P CKAGE PLANT <br /> t ❑ PERMANENT ❑ TEMPORARY t❑ NEW REPAIR ❑ OTHER n <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 M <br /> Plant Capacity r "_ No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑!Mdre Than 1,000 Sq. Ft. ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4 { <br /> I - <br /> A' 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, andru and regula ons San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X + r <br /> D <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received.ByJanuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> i BASE EXPLANATION BILLING REMITTANCE $DATE DATE . REMITTED AMOUNT DUE CHECKED <br /> ` e -. AMOUNT <br /> I{k FEE <br /> LESS <br /> PRORATION # <br /> PLUS ` <br /> ' PENALTY F`p <br /> OTHER 41 <br /> - OTHER <br /> Received by Date =l Receipt No. Permit No. Issua ce Date Mailed Del <br /> ivere <br /> SF <br /> ' <br /> APPLICANT RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCK N,CA 95201 <br />