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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 /> } <br /> LIQUID WASTE <br /> Appl ication reby made_to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> 0 Business Name BA) [ ti �` Address 0� <br /> z Owner Address <br /> a <br /> a J Firm Partners, Addresses and Teleph 'e Numbers <br /> 0. Business Telephone No. Emergency Telephone No. . <br /> Contractor Licence No. `� <br /> L 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 <br /> Description(Make/Yr., Color) t . <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> t No. of Chemical Toilets Stored _ <br /> 3. ❑ PERCOLATION TEST 1 oq <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location t Test Date/Time 11 <br /> 4. X SANITATION PERMIT ( r <br /> Job Address/ n - =� ' "" AC4 <br /> Owner Address <br /> I SEPTIC TANK I ESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ~ <br /> 4-PERMANENT ❑ TEMPORARY NEW, ❑ 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 <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> i <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: IJ Less Than 1,000 Sq. Ft.,• More Than 1,000 Sq. Ft. <br /> j ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 /> kordinances, state laws, and rules re tions of the San Joaq ocal F ealth District. <br /> APPLICANT'S SIGNATURE X <br /> ' FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT KFER SITE ❑ EACH ❑ January 1 &Rece+ved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> f - BASE EXPLANATION BILLING REMITTANCE- AMOUNT DUE CHECKED <br /> DATE - DATE REMITTED AMOUNT <br /> FEE C/ <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> k <br /> OTHER] 3 <br /> Received by Date Receipl No Permit No Issuan a Date Mailed Deliver 6 <br /> APPLICANT—RETURN ALL COPIES TO:--{ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P. BpY 2004 STOC ON,CA ! <br /> 4 7 <br />