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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 /> LIQUID WASTE <br /> Applicatio is hereby ma to carry on "nes i e jurisdictional area of the Sa Joaquin ocal Health District <br /> w Business N (DBA) Addre s <br /> a Owner ,e� � • t <br /> Addrls - <br /> Firm Partners, Addresses and Telephone Numbers tLX <br /> aa' Business Telephone No 35'33 Emergency Telephone No.S11-L. <br /> Contractor Licence No. S"7 1/ aCJ <br /> Applicants Name (Print) cLL .S SL6 Title tTeJ Aa—A. <br /> Date —lO—B/ ) <br /> Please check Applicable Category (1.7)and Fill in the Required Information 6- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) /n <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc tse 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 <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 PERMIT c� <br /> Job Addre /Location ��� c /csce.tt. <br /> O,wn SA Address .,914PO <br /> 9--SEEPAGE <br /> � 4- <br /> Lr�75 SEPT C TANK ❑ CESSPOOL �'CEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> L-T'PERMANENT ❑ TEMPORARY C`YNEW B'REPAIR ❑ OTHER a.. <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �Q <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 rn <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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an I nd regula VFj,9211!San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT \ <br /> FEE Y $ L.4. 0 <br /> LESS fK <br /> PRORATION \ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 13 <br /> Received by Date Receipt No. Permit Na. 0B `8 Issue ce Dete Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 1008 ST&CKTON.CA 85201 <br />