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H Applications Will Be Processed When Submitted Properly Completed. ae Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE - <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> mBusiness Name (DBA) Address <br /> aOwnerin id.11 Inc A Address <br /> Firm Partners, Addresses and Telephone Numers <br /> b` <br /> a Business Telephone No. Emergency Telephone No. (�( <br /> Contractor Licence No. <br /> fApplicants Name (Print) Title CJ cry Dale <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 I <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License 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 <br /> Job Address/Location q0G 7 Q a � O I <br /> Owner _�. _ _ Address <br /> SEPTIC TANK ❑ CESSPOOL ,��BLEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT 11t <br /> TEMPORARY 5k NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -hne 30, 19 <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 <br /> Operator Name Where Certified <br /> Plant Location <br /> E 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, rules and regula 'ons of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> s <br /> FOR DEPARTMENT USE <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Qt PER SITE ❑ EACH ❑ an ry 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING R NCE $ AMOUNT DUE CHECKED <br /> t DATE ATE REMITTED J�yy1�J` AMOUNT <br /> EEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6` � I <br /> Received by-, Dat Receipt No. Permit No Issuance Date MailedDetiv e <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1681 E.HAZELTON AVE.,P.O.Boz 2009 STO TON,CA 85201 <br /> N <br />