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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> ' ra` LIQUID WASTE <br /> Applicati n is hereby made to car n bu ine in the jurisdictional area of the? <br /> Joa in Local Health District <br /> ,F Busine me (DBA) Addres <br /> aOwner Address <br /> U Firm Partners, Addresses and Telephone Numbers r <br /> CL <br /> Business[Telephone No. _��� e �� Emergency Telephone No. <br /> Contractor Licence No. a <br /> L Applicants Name (Print) [ClL Title 640/1PA_ 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. License Renewal No. <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 r <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R C.E. Name R.S. or R.C.E. No. <br /> Test L�a'tion Test Date/Time <br /> 4. Iff SANITATION PERMIT _ <br /> Jab Addres cation <br /> Owner Address �y <br /> ff SEPTIC TANK ❑ CESSPOOL GI-1 EACHING FIELD 2-'SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ 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 certify that I have pre red this plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and reg t' s f 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 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> ASE EXPLANATION DATE DATE REMITTED AMOUNTt�UE CHECKED <br /> AMOUNT <br /> FEE ✓ � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> :751 <br /> '!y '73 1 Ca 1� <br /> Received by pate Receipt No, �� Permit No. Issuance Dat Mailed 6DebverePPLICANT—RETURN ALt COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.tiAZELTON AYE.,P.O.Bax 2609 5CA8 41 Of3 <br />