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i Applications Will Be Processed When Submitted Properly Compieted. Be Sure T <br /> APPLICATION o Sign The Application.' ~ <br /> I - (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> 1 LIQUID WASTE <br /> Application Is h reby made4to car on business in the jurisdictional area of th Sa Joaquin Local Health District <br /> O Business Name (DBA) 1 ! <br /> z Owner Address fh tL�S�tK,� 9 SZp <br /> I Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> dL a Business Telephone No. o - q 7 <br /> Emergency Telephone No. 00 <br /> � Contractor Licence No. S 0 <br /> L Applicants Name (Print) ��� 1, <br /> - Title Date <br /> Please check Applicable Category (1-7)an Fill in the Required Information <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) N <br /> I 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. <br /> Equipment Parking Address <br /> ,2. ❑ PUMPER YARD <br /> I For July 1, June 30, 19 <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION <br /> TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> TestLoc �n 1 Test Date/Time <br /> i 4. u SANITATION PERMIT I <br /> Job Address/Location ba Z17 <br /> Ownerr Address <br /> ❑ SEPTIC TANK El CESSPOOL ACHING FIELD B EEPAGE PIT ❑ PACK f <br /> AGE PLANT <br /> ❑PERMANENT ❑ TEMPORARY ❑ NEW ©p PAIR ❑ OTHER S , <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 f <br /> Type Construction Disposal Site LA <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 1-1PACKAGETREATMENT PLANT For July 1, - June 30, 19 . <br /> Operator Name Where Certified <br /> Plant Location r g) <br /> Plant Capacity No. Units Served 7 <br /> 7. C1 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 /> 3 <br /> 1 hereby certify that I h ve prepared this applicatio and that the work will be done in accordance with San Joaquin County t <br /> ordinances, state laws n rul regul ons he Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE f <br /> f <br /> i FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH .[] January 1 &Received_By( Y Januar Y 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ r REMIT <br /> "f DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS $_ <br /> PENALTY <br /> OTHER <br /> OTHER ; <br /> Received by :, Date - I Receipt No. Permil No, Issuance Date Mailed Deliver d � <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON-AVE.,P.O.Box 2009 STOC TON,C 95201 <br /> e—er <br />