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I Applications Will Be Processed When Submitted Properly Completed. Be'-pure To Sign The Application. <br /> t <br /> APPLICATION <br /> For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl ication hereby made to carry on business in the jur)sdictional area of the San Joa utn Local Health District <br /> Business Name (DBA)" Address <br /> a Owner_M fl C-E W4/-C/j+ Address aS SO, <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. is lo/4& Emergency Telephone No. <br /> Contractor Licence NO. <br /> dt <br /> Applicants Name (Print) Title r 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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. O <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stared • <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 (4 s <br /> 4. IKSANITATION PERMIT 1 <br /> Job Address/Location 3146 r_— S "5 ` 6AI A9ZIA6 <br /> Owner - —Address "49 <br /> L $ tea! <br /> ❑ SEPTEC TANK El CESSP OL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEIN ,�REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 t <br /> Type Construction T Disposal Site <br /> No, of Units t 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 I <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, a ules and re uI t'ons of the an Joaquin Local Health District. <br /> 5 <br /> APPLICANT'S SIGNATURE X 'I <br /> f FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑.ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑.January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE ,, DATE. REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE GIs I Y <br /> LESS ! U J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER In ` <br /> Received by - Datet Receipt No. Permit No.. Issuance Date - Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO:' .,ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON.-AVL,P.O.Box 2009 STOCKTO CA 45 1 <br />