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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 /> y LIQUID WASTE <br /> Application is hereby made to carr business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) LDCs - <br /> Address <br /> a Owner - - Addressooll <br /> G <br /> i J Firm Partners, Addresses and Telephone Number <br /> aBusiness Telephone No. -- Emergency Telephone No. <br /> Contractor Licence No. 1 <br /> Applicants Name (Print) Title <br /> Date , <br /> k 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:noe Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> r For July 1, June 30, 19 <br /> No. of Vehicles Stored i <br /> No. of Chemical Toilets Stored <br /> ? <br /> 3. E] PERCOLATION TEST;.: N� , <br /> R.S. or R.C.E. Name Jr _ -R- _R.S.-or-R.C.E. No. 4 <br /> Test Location Tes Date/Time <br /> ",t- ❑ SANITATION PERMIT <br /> Job Address/Location c� C <br /> Owner .,. �..�T�.._,.. . ,�. _...� �1 �.:.. _�. Address—_,�.. � ,.�-,_ -�-� -1- -- <br /> de,52 <br /> ❑'SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY El-NEW .- z 0-REEPAIR_ ❑ OTHER a <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal-Site ^ ` %* F <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July,1J_une�30, 19� <br /> Operator Name _ Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY F6r`July.1,--June 30, 19 y <br /> y fi +i <br /> SIZE: _ ❑ Less Than 1,000 Sq. Ft., El More Than 1,000 Sq. Ft. }l <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo., <br /> !!y <br /> I hereby certify that I have preparedrthis_ plication-and that-the_work-will_be_done in_accordance with San Joaquin County <br /> ordinances, state laws, and rules and•re do f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X =¢ n <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: It ANNUALLY El PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31-1y�, ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT':DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE -S <br /> 3 •' F <br /> _LESS--- <br /> PRORATION <br /> PLUS <br /> PENALTY -�n..::,A; ', '4 .-_"t4 <br /> OTHER - <br /> i <br /> OTHER <br /> _ Q 5 1r�� 1 (� 17 i <br /> Received by Date Receipt No. Permit No. 'Issuartce Date Mailed elrvered <br /> APPLICANT-RETURN ALL COPIES TO: ''ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.-HAZELTON AVE.,P.O.Box 201019 STOCKT ,CA 95 1 <br />