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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application, " <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) I <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is ereby made to arryon busi s in the'uris lictional area of the an Joaquin Local Health District <br /> Business Name A) '' l4ddress 7k 77 <br /> aOwner Address i <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aa. Business Telephone No. �L, DCl <br /> a Emergency Telephone No. <br /> Contractor Licence No, Z. <br /> I <br /> L Applicants Name(Print) Title Date ]-g/� <br /> Please check Applicable Category(1-7) and Fill inthe Require Information r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) v�(ti <br /> For July 1, June 30, 19 Disposal Sites DU <br /> Description(Make/Yr., Color) , <br /> Serial No. CAL. License No. CAL. Licr_nse 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 /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test LP61 Test Date/Time <br /> 4, LU SANITATION PERMIT �] <br /> Job Address/ do 7 M <br /> Owner Address c!^ <br /> ❑ SEPTIC{ ❑ CESSPOOL LEACHING FIELD ❑ ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Uy <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) U.1 <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 /> 7. ❑ 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and gulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X G <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> RASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE � � � q� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY /, <br /> OTHER ' <br /> OTHER <br /> 3 <br /> 6- <br /> Received by Date Receipt No. Permit No. Iss ance Maled [Ye livered I ,X. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �` <br /> 1601 E.HAZELTON AVE., DrBbx.2�p@_,�7gCKTgN,`EA.9520i', <br />