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�- --� <br /> Applications Will Be Processed When Submitted raper <br /> APPLICATION SEPTAGP <br /> s (For Non-Transterable,Revocable,"and Suspendable) <br /> ENVIRONMENTAL.HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area osthe San Joaquin Local Health District <br /> 1E5 1 l G�. e ca-o <br /> rn business Name (DBA) L1�a i -5 Address <br /> a Owner - <br /> t�23- q S <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No. G Date L <br /> Title t <br /> Applicants Name (Print) [1 <br /> ion <br /> Please check Applicable Category (1-7)and Fill In the Required Intormat - �, •_ �} <br /> 1. ❑ PUMPER VEHICLE PERMIf REGISTRATION (FOR EACH VEHICLE) <br /> June 30, 19 4 -Disposal Sites <br /> For July 1", <br /> Description(Make/Yr.,Color) CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> i <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> p- ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> t <br /> No. of.Vehicles Stored . - <br /> No. of Chemical Toilets Stored ` <br /> ( 3, ❑ PERCOLATION TEST R,S. or R.C.E.No. <br /> ` R.S. or R.C.E. Name t Test Date/Time <br /> Test Location <br /> a. Gr SANITATION PERMIT/ Q Q 1.2D / p t Ll <br /> Job Address/Location Address <br /> Owner ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT S X�S f �rO <br /> 13 SEPTIC TANK ❑ CESSPOOL ❑ NEW REPAIR 11 OTHER # i <br /> 11 PERMANENT ❑ TEMPORARY �" <br /> 5• ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) ; i! <br /> I g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified t <br /> Operator Name IF — �..s. <br /> ! Plant Location , No. Units Served r <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> that the work will be done in accordan <br /> I hereby certify that 7 have prepared this application and ce with San Joaquin County <br /> ordinances, state laws, and r les and regulations of the San Joaquin Local Health District. 7;�NW PO4 O <br /> APPLICANT'S SIGNATUREX ,�f <br /> jet© <br /> 41 <br /> FOR DEPARTMENT USE ONLY <br /> PER UNIT ❑ PER SITE El ❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July <br /> 31 <br /> Fee Is Due: ❑ ANNUALLY _❑ -REMIT <br /> . BILLING I REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> � s ° <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> -.� OTHER <br /> ived by Date Receipt No. <br /> Permit No Issuance Date Mailed Oelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 1601 E.HA2ELTON AVE.,P.O.Bol 2009 STOGKTON,CA 95201 <br />