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TObign Itne <br /> Applications Will Be Processed When Submitted Properly Completed. BeSure <br /> APPLICATION <br /> (Far Non-Transferable,Revocable, and Suspendable <br /> SEPTAGE ` <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LlQU.10 WASTE ocal Hea tfi District <br /> Applicatia is hereby m e to carryusi ss the jurisdictional area of the Sa Joaqui 1j <br /> _Address <br /> N Business <br /> Address <br /> i Owner_ <br /> aFj <br /> Firm Partners, Addresses and e4�ph ne N bers Emergency Telephone No. �d <br /> aBusiness Telephone No. Q / _ d <br /> Contractor Licence No. Title <br /> !A Date <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information + <br /> 1. ❑ PUMPER VEHICLE PERMiT REGISTRATION (FOR EACH VEHICLE) <br /> June 30, 19 <br /> For July 1, Disposal Sites � <br /> Description(Make/Yr., Color) CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Gal., Weights & Measures No. <br /> Capacity <br /> Equipment Parking Address 7 <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 R.S. or R.C.E. No. <br /> R.S. or R.G.E. Name Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT��Job Addr s/ c tio <br /> l� <br /> ress <br /> Ail <br /> Owner �,/ ❑ PACKAGE PLANT <br /> aYSEPTIC TANK ❑ CESSPOOL UKEACHWG FIELD 1� SEEPAGE PIT ❑ OTHER <br /> Q PERMANENT ❑ TEMPORARY 93 NEW ❑ REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE.TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> € 7. ❑ LAUNDRY For July 1;-June 30, 19 <br /> k 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 prep ed this ap cation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r c d regul Kbm o he San Joaquin Local Health District. <br /> F <br /> APPLICANT'S SIGNATURE X <br /> I FOR DEPARTMENT USE ONLY <br /> 31 <br /> F REMIT <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH '❑ January 1 &Received By January 31 July 1 &Received By July <br /> L BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> F LESS <br /> l PRORATION <br /> f PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> `7 e ere <br /> Receipt No- Permit No. Issuance Dale Mailed <br /> Received by - Date 1601 E.HAZELTON AVE.,P.O.Bo 2009 STOCK ON,CA 201 <br /> t - ti APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALT�PERMITISERYICES h�� <br />