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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> '4,v <br /> 4 � 5 �! LIQUID WASTE 10t - V7 —eG <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> HBusiness Name/(DBA) '"� Address ' <br /> Lr p✓�r Pn r^c e- / .S .y�rr C'Y- �✓I�.`'71a La o:F <br /> a Owner ✓ Address- �^ <br /> J Firm Partners, Addresses and Telephone Numbers 4 7 7',�s 9 8& <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) ;./ •' Title awn c+- Date f BCS <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) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. i <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 N <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Loc r'/ o-12Test� Date/Time <br /> 4. W SANITATION PERMIT <br /> Job Address/Location /mar-ems p �7r+drr� ��,.�- k./4 zae7c <br /> Owner— Address <br /> PEPTIC <br /> TANK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY MINEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 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 4L <br /> Plant Location 1 <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 /> 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 rul and re tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> EK <br /> FOR DEPARTMENT USE ON y <br /> Fee Is Due: 11 ANNUALLY PER UNIT E PER SITE 13 EACH ❑ Januar & ived By Qnuary 31 ❑ July t &Received By July 31 <br /> BILLING REMITTREMIT <br /> A E <br /> EASE EXPLANATION DATE DAT R I ED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS V <br /> PRORATION AO <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> S/3 <br /> Received by t0ate Receipt No. Permit No. Issuance Date Mailediuer d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC TON,CA 5201 <br />