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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign-The Application. <br /> � <br /> APPLICATION <br /> _ (Far Non-Transterable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is eby-made to arW on busin ss in t e j ri Ic tonal area of the S oaq 'n Local Health <br /> ,FBusiness Nam p[3BA) G Address._ t7 � _ 1 <br /> aOwner A Address , <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �� `���•� - _ Emergency Telephone No. <br /> i -i Contractor Licence No. z Z <br /> Applicants Name {Print) l `z`� Title Date <br /> Please check Applic�ble`Callegory (1-7)and Fill in the Required Information <br /> j 17,0_;PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr,GTolor) <br /> Serial No. * CAL. License No. CAL. License Renewal No. <br /> f <br /> Capacity r Gal.,Weights & Measures No. <br /> j Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 . <br /> No. of Vehicles Stored I <br /> No. of Chemical Toilets Stored w <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R,C.E. Name •r R.S. or R.C.E. No.x 4 <br /> v <br /> Test Location Test Date/Time # <br /> 4. ❑ SANITATION PERMIT . ; <br /> ! Job Address/ cfltl <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ EACHING FIELD 2 SE PAGPIT2 ❑ P CKAGE PLANT <br /> 11PERMANENT ❑ TEMPORARY 11NEW M REPAIR ❑ OTHER j <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site ; - <br /> No. of Units Equipment Storage/Cleaning Location{s) l j <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �i <br /> Operator Name -- Where Certified .'' <br /> Plant Location I J- <br /> Plant Capacity No. Units Served . <br /> T. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq: Ft. <br /> N <br /> ' ❑ DRY CLEANING, Chemicals Used/AmounVMo. <br /> I hereby certify that I have prepared this application and,that the work will be done in accordanc vvjh San.Joaquin County <br /> ordinances, state laws, and rules and re lations of the Sa' qui Local Health district. [Ul <br /> 161 <br /> APPLICANT'S SIGNATURE X <br /> L <br /> FOR DEPARTMENT USE ONLY <br /> ti <br /> Fee Is Due., ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J uar } eceived By January 31 ❑ July 1 S Received By JuYy 31 <br /> 'BILLINGREMITT $ REMIT X111. <br /> BASE EXPLANATION DATE DA REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER . aye <br /> OTHER <br /> Received by Date Receipt o. Permit No. Issuance Date Mailed- Delivered <br /> . - APPLICANT—RETURN ALL COPIES TO: ENYIRONM NTAL HEALTH PERMITISERVICES 'Y691 E.HAZELTON AVE.,P.O.fox ST CKTON,CA 95201 <br />