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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign ThkApplication. <br /> - APPLICATION r <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> w LIQUID WASTE <br /> Application is herebyma a to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) /9air'6 V $O Address <br /> z Owner &e �J��l t Address =V ' e <br /> q , <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness,Telephone No. Emergency Telephone No. <br /> Contractor Licence No. z ✓��6 <br /> LApplicants Name (Print) Gr Title x Date g <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. Licc nse Renewal No. <br /> Capacity Gal.,Weights & 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 /> 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 /> f 4. X SANITATION PERMIT <br /> Job Address/Location �3✓r �!"`l �A/% � ��55 !<.� �r �1� G/9 r <br /> Owner _ TXC. C-6,4111- >1 Address ' <br /> SEPTIC TANK ❑ CESSPOOL f .� LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br />`. ❑ PERMANENT ❑ TEMPORARY Ill NEW E] REPAIR ❑ OTHER r <br /> 5. 13CHEMICAL TOILETS For July 1,'-,June 30, 19 . T <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 I <br /> Operator Name Where Certified <br /> E Plant Location <br /> I Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑f More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> J <br />� � f <br /> d <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 rules aP40egulation of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 0 <br /> REMIT <br /> BILLING REMITTANCE $- <br /> _ BASE - EXPLANATION PATE A REMITTED -- AMOUNT DUE- CHECKED- - <br /> 1 r <br /> AMOUNT <br /> FEEal'L V <br /> PROLES -7 <br /> PRORATION i J <br /> PLUS } I <br /> PENALTY F l <br /> OTHER ; <br /> OTHER <br /> 1 Received by Date Receipt No. Permit No Issuance Date Mailed Deliv ed f <br /> ( - . APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.BOX 2009 STO .TON,CA 95201 <br />