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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Tranaferable,~Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is her y made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) LI � �u'LU( Address v <br /> Z3 4e C-4 <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. _ Emergency Telephone No. <br /> Contractor Licence No. <br /> Title ✓ Date <br /> Applicants Name (Print) A. . / <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) lS` <br /> 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 /> 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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location ` <br /> Address <br /> O,wne <br /> Ifd�SEPTIC TANK CESSPOOL V�ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 . <br /> Type Construction _ -.__... _ Disposall ite - d <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ` <br /> Operator Name '� <br /> 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 accorda J Out County <br /> ordinances, state laws, and rules and re ation of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X / <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 0 July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE � s �S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> h <br /> Received by Date Reeei tNo ,air P" a y s! 15Suance ate WiledOelwerEdx` '*r„•1 <br /> y � <br /> APPLICANT—RETURN ALL COPIES TO: ENYIl*GN'MENTAi:FIEkL'1'kF J=RM1715E.Ii41EE'S } '601,F_HA2ELTON kVE -R.O 9oz 2009 :STOCt('tON,CA 95201 <br /> K <br />