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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 arty o usiness the jurisdictional area of the S Joaqu Local HoAea�1th Dis t <br /> Business IN (DBA) YVIV Addres - d 95�— <br /> z Owner LS'7"�s/s Address �� <br /> F a i ;l <br /> Firm Partners, Addresses and Telep'hone Numbers <br /> 0. Business Telephone No, Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) < <-« Title —OWE Date ' �� 1 <br /> ,F <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) IF <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity a Gal., Weights & Measures No. <br /> Equipment Parking Address_ �1 <br /> 2. ❑ PUMPER YARD {� <br /> For July 1, June 30, 19 _ <br /> No, of Vehicles Stored 'f <br /> No. of Chemical Toilets Stored <br /> l 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. E SANITATION PERMIT !� <br /> Job Address/Location"y i r <br /> Owner II Address <br /> ASEPTIC TANK CESSPOOL WLEACHING FIELD &MEPAGE PIT ❑ PACKAGE PLANT <br /> 9TERMANENT ❑ TEMPORARY SINEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction M Disposal Site C <br /> No. of Units II Equipment Storage/Cleaning Location(s) 0 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name _Where.Certified <br /> Plant Location i <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -Julie 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 <br /> I hereby certify that I have red this applic nand that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rul and regulatio of e n Joaquin Local Health District. <br /> II <br /> APPLICANT'S SIGNATURE <br /> i A n 7 <br /> FOR DEPARTMENT USE ONLY F <br /> Fee IS Due: 11ANNUALLY C1PER UNIT 11PER SITE , ElEACH 11 January 1 &Received By January 31 ElJuly 1 &Received By July 31 I <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY p <br /> OTHER : <br /> OTHER n <br /> y <br /> oIl <br /> Received by Date Receipt No. PermifNo. Issuarice Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO'. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.Q.Box 09 �TOCK OON,CA 952D1 F <br />