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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 /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area oft an Joaquin oval Health District <br /> y Business Nagle (DBA) Address \ <br /> a Owner Address <br /> J Firm Partners, Addresses and T lephane Numbers <br /> aBusiness Telephone No. 6Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) - �� At r Title Gll�lti/e 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. <br /> Capacity ti' Gal., Weights & Measures No. Q <br /> Equiprrent-Parking Address.-� + <br /> 2.,❑ PUMPER-YARD.t <br /> For July 1,— °Jtjne 30; <br /> No. of Vehicles Stored <br /> "IVo:.ofiChemical,Toilets Stored <br /> 3 ❑ PERCOLATION TEST <br /> R.S. or R.C.ErNafne- i'= R.S. or R.C.E. No. d <br /> Test Locatiori" .— Test Date/Time r <br /> 4. ❑ SANITATION PERPoiIT <br /> Job Addr /Location ' `CJtJ y <br /> Owner �`_ 'S Address 171?4q <br /> ZJtPTIC TANK IQ L @;-- ACHING FIELD Cr SEEPAGE PIT ❑ PA_CKAC}E PLANT •*F <br /> JRPERMANENT ❑ TEMPORARY IQ NEW ❑ <br /> REPAIR >❑ OT, <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning1L`ocation(s) 717 <br /> 6. 11PACKAGE TREATMENT PLANT For July I,'-June 30, 19__ n <br /> Operator Name <br /> O tor N ' ' <br /> p +_ 7 �Wltere Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: El Less Than 1,000 5q. Ft., 13 More Than 1,000 Sq,.Ft"W <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I ve pre red this application and that the wor ill be done inJaccordance withi San"Joaquin County <br /> ordinances, state law and ules d regulations of the San Joaquin L c Health District. i <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 fir❑FJuly 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASF EXPLANATION AMOUNT DUE CHECKED I <br /> DATE DATE REMITTED rW AMOUNT <br /> FEE <br /> LESS 3 <br /> PRORATION <br /> PLUS t <br /> PENALTY I <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. � -Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES To! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTOi 95201 <br />