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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> y. D�/ %J✓.Cj (For Non-Transferable;Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH_ PERMIT �} <br /> ' LIQUID WASTE M1 - <br /> RPr <br /> Application is hereby made to carry on business in 1he.jurisdictional area of the San Joaquin Local Health District. <br /> F Business Name (DBA) _ Address <br /> ~ 6Z Sc <br /> z Owne Address <br /> J Firm Partners, Ad esses and Telephone Numbers r <br /> Q. Business-Telephone No. - , - Emergency Telephone No. <br /> Contractor Licence No. <br /> L,Applicants Name (Print) Title - Date F <br /> Piedse 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) <br /> Serial No. CAL. License No.• CAL. License Renewal No. <br /> Capacity Gal.,.Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD c <br /> For July 1, June 30, 19 — <br /> No. of Vehicles Stored <br /> No. Chemical Toilets Stored <br /> 3. IJ PERCOLATION TEST <br /> R.S.lorKC,E. Name R.S. or R.C.E. No. <br /> Test Location 1 Test Date/Time <br />~ 4. 1.3 SANITATION PERMIT r, g} <br /> D -21 <br /> oti Ad ess/Location Q r I� -.o_'� !fir` <br /> OAddres <br /> fifSEPTIC TAN ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> �I PERMANENT ` ❑ TEMPORARY NEW <br /> REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �+ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July.'1, -June 30, 19 <br /> Operator Name I Where Certified <br /> Plant Location 1 <br /> Plant Capacity I No, Units Served <br /> 7.-❑ LAUNDRY For.July 1, -June 30, 19 _. - - - 4 <br /> SIZE: Ot❑ Less Than 1,000 Sq', Ft.,' 0 More Than 1,000 Sq. Ft. ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ti <br /> i <br /> I hereby certify that l'have`prepared this application and'that the work-will be done in accordance with San Joaquin County } <br /> ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S <br /> 1V ..FOR DEPARTMENT USE ONLY. <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH :❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 4 i • REMIT <br /> BASE EXPLANATION BILLING REMITTANCE �� AMOUNT DUE CHECKED <br /> DATE >DATE - `REMITTED - AMOUNT <br /> 6 <br /> FEELESS <br /> 'PRORATION !' <br /> PRORATION <br /> PLUS <br /> PENALTY . <br /> OTHER _ . <br /> OTHER F F <br /> F <br /> ` Received ate 'Receipt No. Permit No. Issuanc9f Date Mailed Deliver d <br /> - <br /> APP Lk NT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES "- 1601 E.HAZELTON AYE.,P.O.Bax 2009 STOC TON,CA5201 <br />