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:.Applications Will B iProdessedd When Submitted Properly Completed. Be Sure To Sign The Application; <br /> APPLICATION <br /> �N (For Non-Transferable, Revocable, and Suspendable) <br /> ii ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> -� LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the S n Joaquin Local Health District <br /> y Business Name (DBA) v Addressf' C�► <br /> F <br /> zz OwnerAddress i <br /> J Firm Partners, Addresses and Telephone Numbers ! <br /> a Business Telephone No. `5 r� Emergency Telephone No. <br />! a <br /> Contractor Licence No. r'� <br /> E L Applicants Name Print) L Title <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 V Disposal Sites <br /> Description(Make/Yr., Color) _ <br /> Serial-N67777- `'"_-7 ` " ' CAL:Lice ,;e Renewal No: <br /> Capacity ' . Gal., Weights & Measures No. <br /> Equipment Parking Address C <br /> 2. ❑ PUMPER YARD ` i. <br /> For July 1, June 30, 19 ; 3 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilet§Stored ( ° "mt <br /> 3. ❑ PERCOLATION TEST i <br /> J LL ; r �-:: a <br /> R.S. or.R.C.E,_Name R.S.or-R.C-.E'No.� r <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT rt7:' (� <br /> Job Address/Location "' � _. �C �{ n C�lsl .aC <br /> Owner . ., _ y :– Address y A , T <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT_ © PACKAGE PLANT t y- <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER. s <br /> 5. 0_'CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site i <br /> No. of Units .. Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name r �•' °_Where Certified <br /> Plant Location _ _ -' ` <br /> Plant Capacity _No. <br /> -Uniis.Served <br /> 7. [],LAUNDRY For July 1, -June 30, 19:!z_ "f <br /> SIZE:-.% ❑ Less.Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> •: .r '4, 4 <br /> ❑ DRY CLEANING, Chemicals Used/Amounf/Mo.:- <br /> s I hereby-certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> E ordinances, state laws, and rules an regulations of the San Joaquin Local-Health District. <br /> I APPLICANT'S SIGNATURE X <br /> S <br /> L <br /> I , <br /> y FOR DEPARTMENT USE ONLY r ; <br /> !Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Ju3y 3t <br /> 4 <br /> (g BILLING - REMITTANCE $ 'REMIT <br /> i - BASE EXPLANATIONv DATE DATE REMITTED - AMOUNT DUE CHECKED <br /> i AMOUNT <br /> FEE L <br /> LESS <br /> +PRORATION <br /> +PLUS <br />' OTHER �; —�I �� <br /> "'� <br /> �' •.. OTHER....-f- <br /> 07 . <br /> Received by - DAte Receipt No. - Permit No. Issuance Date Mailed elivere <br /> i - APPLICANT-RETURN ALL COPIES TO: --ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.'Box 2008 STOCKT N,CA-95201 } <br />