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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. a Y_ - <br /> APPLICATION <br /> ' (For Non-Transferable, Revocable, and Suspendable) r- <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> F Applicati s ereby oto rry on b ness-in the jurisdictional area of the San Joaquin cal eal D' ct <br /> rn Business e(D8 ) ^�- Address �� <br /> l'- <br /> Owner Address p.F <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. '� lo�4 Emergency Telephone No. <br /> � Contractor Licence No. <br /> �3 <br /> Applicants Name (Print) Title Date_ <br /> Please check Applicable Category(1-7) and Fill in a Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �. <br /> For July 1, June 30, 19 Disposal Sites <br /> III_ <br /> Description(Make/Yr., Color) <br /> I Serial No, CAL. License No. CAL. License Renewal No. Ir <br /> Ir <br /> \- <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 Location Test Date/Time <br /> SANITATION PER <br /> J <br /> ob Ad ess/Locati n <br /> Owner Address Q ! 4 -Q <br /> W SEPTIC TANK ❑ CESSPOOL % LEACHING FIELD O SEEPAGE PIT ❑ PACKAGE PLANT <br /> _ <br /> PZPERMANENT �❑ TEMPORARY 9 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 � '"' 4 <br /> Type Construction Disposal Site- 01 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> I's. ❑ PACKAGE.TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified �. <br /> Plant Location <br /> Plant Capacity <br /> No. Units Served <br /> 7. 11LAUNDRY 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. i <br /> I hereby certify that I have prepared this application and that the work willbe done in accordance with San Joaquin County 1 <br /> ordinances, state laws, and les and regula ion, of the 5a Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X yy <br /> 9 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED UNT DUE CHECKED <br /> FEE �i AMOUNT <br /> LESS T <br /> PRORATION <br /> PLUS j <br /> PENALTY <br /> OTHER <br /> _ a} <br /> OTHER <br /> Received by Date Receipt Na- Permit No. <br /> Issuance Date Mailed Ilelivere <br /> APPLICANT-RETUF(N ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES- 1601 E.11AZELTON AVE.,P.O.Box 20Q9 STDG ON,CA 95201 <br />