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Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheApplication <br /> lAPPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> _ } t4�w� ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appiic is he by m car on busdiness n un dictional area of the S n aqum ocal Healt Di ri <br /> r /�CG'� -- _ ['�� /r Address <br /> Business Name (DBfA}7� <br /> aOwner Address C,tjrj Address <br /> Firm Partners, Addresses and Telephone Numbers # <br /> a Business Telephone No. ��z d Emergency Telephone No. <br /> a <br /> Contractor Licence No. r Q <br /> Applicants Name (Pring Title `s/� Date r. <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 <br /> Description(Make/Yr.,Color) 4 _ n <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> R w � <br /> Capacity Gala,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 3 :. <br /> No. of Vehicles Stored t <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 ►r, I l <br /> 4. SANITATION PERMIT �if,f' 17 a� �i�'7�� /��/ �• �O� 7 <br /> Job Add s/Location ■-'c!G! /'T �u <br /> Owner , r Address E <br /> SEPTIC T NK ❑ CESSPO L - ;g LEACHING FIELD ]9SEEPAGE PIT ❑ PACKAGE PLANT: l <br /> PERMANENT C3TEMPORARY NEW ❑ REPAIR I ❑ OTHER "C�[ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s)—IJit <br /> �? <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Where Certified <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. El LAUNDRY For July 1, -June 30, 19 <br /> rt <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. t <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I 1� <br /> I <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, a s and regulati ns of the San Joaquin Local Health District. <br /> rt <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPART T USE ONLY <br /> Fee Is Due, ❑ ANNUALLY 0 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> ;BASEEXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE. S_ OQ <br /> LESS <br /> PRORATION <br /> PWS + <br /> PENALTY <br /> OTHER } # `Y1 <br /> OTHER <br /> 79 <br /> m7 <br /> Received by Date Receipt No. Perms No. issuance <br /> Date Mailed --- Deliver 4 Jr 7 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST D ,C 95201 <br />