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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 /> >r ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i hereby made to carry oQApsiness in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address l Y <br /> t a Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. �� 5 1 _ Emergency Telephone No. - <br /> Contractor Licence No. <br /> L Applicants Name (Print) r ". - Title l ZP AeC-E Date n7— 67-2-17!3 P <br /> V; <br /> Please check Applicable Category(1-7) and Fl 11 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 /> i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ? <br /> For July 1, I June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST= <br /> C R.S. or R.C.E. Name ; t R.S. or R.G.E. No. l <br /> Test Location j Test Date/Time : <br /> i W <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location%'_ .pis': fl /!lCW4 r�.6,k14 �✓ r? + �" ! <br /> Owner •r Address o <br /> ASEPTIC TANK, 11 CESSPOOL LEACHING FIELD ❑ 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 i i Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name I—' s ; Where Certified f t <br /> Plant Location <br /> . . <br /> i, <br /> Plant Capacity j Y. No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19— <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 170007Sq:Ft:;""�`rMo,e Than 1,000 Sq. Ft'. <br /> ❑ DRY CLEANING, Chemical sed/A t/M <br /> uo <br /> G f� j <br /> {.�...z <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,.and_rules-ands. gulations-of-the-San-Joaquin Local Health District. <br /> ! i x <br /> APPLICANT'S SIGNATURE X <br /> Al- <br /> I # r FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY <br /> LJ 11NIT-T" P FI ITE'_ EA�H„T` ❑ January'1�&'Received By.January 31 ❑ July 1 &Received By July 31 <br /> } BILLING REMITTANCE $ REMIT <br /> BASE ' EXPLANATION DATE AMOUNT DUE CHECKED <br /> { r j DATE REMITTED AMOUNT <br /> FEE <br /> F <br /> LESS { ' <br /> PRORATION <br /> PLUS ? _ <br /> PENALTY <br /> OTHER <br /> OTHER ' <br /> If 0 <br /> Received by Date _,-r-Receipt No mit No._ - --- Issuance Date Mailed Del- r d <br /> --APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH;P_ERMITlSERVICES "' 1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,CA 201 <br />