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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) j <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE I <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> FBusiness Name (DBA)_ f�^"T/tC/ '1/ �` . S-fY Address <br /> C Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. -3a <br /> Emergency Telephone No. <br /> Contractor Licence No. <br /> 4 Applicants Name (Print) ( Title Date <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 _ p <br />€ Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity Gala, 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, 9-SANITATION PERMIT <br /> Job Address/Location vp 51, -3 Lalf/ <br /> Owner f %y Address 510'yF <br /> W SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 'f <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW • ❑ REPAIR ❑ OTHER 0 � <br />' <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> W <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 /> 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 /> t <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San J unty f l <br /> ordinances, state laws, and rule nd re uI tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ` <br /> FOR DEPARTMENT USE ONLY <br />! <br /> Fee Is_Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> kBILLING REMITTANCE '$ REMIT I <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE r��-'�,J• ��� � <br />' LESS • } <br /> PRORATION f - <br /> PLUS <br /> PENALTY # ' <br /> OTHER i <br /> OTHER - q{ <br /> _ 3 <br /> Received by Date ReceiptNoPermit No. I suance Date *Mailed Delivered <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZEL-TON AVE.;P.O.Box 2009 STOCK101y?CA95201 ''� <br />