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Applications Will Be Processed When Submitted Properly Complbted. Be Sure To Sign The Application. .R <br /> APPLICATION <br /> " (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is ereb made'to carry on b iness in the jurisdictional area of the San quin Local Health District ~ <br /> FBusiness Name (DBA) rL Address r 4>1 G <br /> a Owner d�- Address l !� !G <br /> J Firm Partners, Addresses and Telephone Numbers <br /> t a Business Telephone No.... k y� — Emergency Telephone No. <br /> Contractor Licence No. tzsa <br /> Applicants Name (Print= <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, Renewal No. P <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 r j <br /> R.S. or R.C.E. Name.. R.S. or R.0 E. No. <br /> r <br /> Test Location Test Date/Time <br /> 4. 041SANITATION PERMIT . s <br /> 17 <br /> Job Address/Location L(j J—r �.. <br /> Ow ~� Address .�� .� }4-z �2 Q <br /> SEPTIC TANK ❑ CESSPOOL EACHING FIELD 11SEEPAGE PIT �11 PACKAGE PLANT <br /> ❑ PERMANENT t; ❑ TEMPORARY �I NEW ❑ REPAIR ❑ OfHER <br /> 5. ❑,'CHEMICAL TOILETS For Ju y 1, -June 30, 19 - � <br /> Type Construction ( 'Disposal-Site- <br /> No, <br /> Disposal Site No,of Units ` Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> E Operator Name <br /> Where Certified <br /> Plant Location ) ^a,.4 _ <br /> Plant Capacity ? No. Units Served _ -•— - a �" <br /> T. ❑ 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. 4 <br /> M L - <br /> 1 hereby,,certify that I have prepared this applicatiori and that the work will be done in accordance with San Joaquin County' 4 <br /> ordinances, state laws, and rules and re ulatio of the S n Joaquin Local Health District. _ m <br />! APPLICANT'S SIGNATURE"X _ t <br /> .R �� -1'' .+�•�.'.--�'.-•:-�''tir�-'.. .fir_+-=-�:,—w.r, - yp-: i � :l� <br /> 556 <br /> S 1, <br /> g FOR DEPARTNIENT'USE ONLY <br /> s s <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ER SITE ❑ EACH ❑ January 1 &Received By January 31; Q July 1 &Receivetl By July 31 <br /> ? BILLING d REMITTANCE--- --^�- $ - - _ - REMIT <br /> BASE EXPLANATION q <br /> i ±,DATE REMITTED AMOUNT DUE AMOUNCHECKEp <br /> 1 DATE l <br /> FEE' I 7v GlJ <br /> LESS r . <br /> PRORATION ; k <br /> PLUS <br /> ' PENALTY <br /> f' <br /> -OTHER _. e r- 3., - r �j Q- <br /> OTHER <br /> I <br /> Received by _ Date - Receipt No. Permit No. Issuance Date - Mailed sliver - <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON_AVE.,P.O.Box 2009 SToc ON,CA 95 01 <br />