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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> S\ ' <br /> (For Non-Transferable, Revocable,and Suspendabie) 1 <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE -� <br /> LIQUID WASTE <br /> Applicat' he ebya to car on bus' s in th jurisdictional area of the San Joaquin Local Health District ; <br /> y Business Name (DRAI hd170 " f 4c- Address f <br /> a Owner_ LIA hITYCA/ Address <br /> Firm Partners, Addresses and/Tel pone Numbers <br /> m Business Telephone No. '7 S —,:a irf 6. Emergency Telephone No. <br /> Contractor'Licence No. l <br /> L Applicants�Name (Print)s L Title jC7_;;> Date ' <br /> Please c e'-ci�AppliCabie,Ca[egory(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPERjV,EHICL'E 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. ` n <br /> Equipment Parking Address v ' <br /> 2. 11 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored .No. of.Chemical Toilets Stored - <br />` 3. ❑ PERCOLATION TEST 7+ G <br />` R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test LocationTest Date/Time . <br /> 4. 11SANITATION PERMIT g <br /> Job Address/ ocation O ®� <br /> Owner e Address A 49 S <br /> XSEPTIC TANK ❑ CESSPOOL LEACHING FIELD =9EEPAGE PIT ❑ 'PACKAGE PLANT <br /> YrPERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> l 5. ❑ CHEMICAL TOILETS For July 1, -June 3t)y, 19 <br /> Type Construction { Disposal,Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July i, -June 30, 19 <br /> Operator Name I 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., 0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have r pared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws d r and regulati s of thean Joaquin Local Health District. <br /> APPLICANT'S SIGNAT I REX <br /> FOR DEPARTMENT USE ONLY r� <br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT PER SITE ❑ EACH ❑ January 1,&Received By Janu ry 31 ❑ July 1 &Received By July 31 <br /> REMITTANCE <br /> T REMIT <br /> BASEyEXPLANATION BILLING <br /> DATE ATE REMITTED AMOUNT DUE AMEOUND <br /> s <br /> k FEE <br />` . . <br /> LESS <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I r <br /> f I <br /> OTHER s f <br /> I CJ <br /> Received by Date- Receipt No Permit No. Issuance Date Mailed Deliver d <br />` APPLICANT"RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.NAZELTON AVE.,P.O:l3ti�2(!09 STDC ON.C 95201 <br />