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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> K-.. -> APPLICATION <br /> l (For Non-Transferable, Revocable,and Suspendable) ' <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to car on busin in the'un dictional area oft an Qaquin Lo I He th istrict <br /> rn Busines}� Name IDBA) s Address U <br /> zOwner L.Ear4�l._� !F UC Address <br /> Firm Partners, Addresses ar6Tolhone Nu ber <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. ff <br /> L Applicants Name (Print)_�\&L eLt—T <br /> f L l Title r K, Date <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. U� <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 Location Test Date/Time <br /> 4. ❑ SANITATION PERM <br /> Job Addr s/ ocation <br /> Owner Y Address QA <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD f9 SEEPAGE PIT ❑ PACKAGE PLANT <br /> F PERMANENT ❑ TEMPORARY NEW ❑ 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 cert11 at I have prepared this ap lication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la andul� es acid r2gu,lati f San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> .1", <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT IR PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> / Ji r AMOUNT <br /> FEE I3 vlt)ILESS <br /> U �J <br /> PRORATION <br /> PLUS i C Cv S % T Nv} (1c-e <br /> �l <br /> PENALTY /Je,C /fit j <br /> OTHER irC�r'f?Cf 1�n� �l 3` l !� <br /> 1_ <br /> OTHER w <br /> Received by Date Receipt No. Permit No-.W Issuance Date MailedDeljed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Boz 2009 S70ON,CA 201 <br />