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Appllcations�Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication <br /> y APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) l <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to Garry on business in the jurisdictional area of the S'a'""n Joaquin Local Health District <br /> yBusiness Name (DBA)L• GS o +v s 3 Address ,�ra <br /> a Owner <br /> Address Cr L <br /> J Firm Partners, Ad resses and Telephone Numbers <br /> CL —G G Emergency Telephone No. �. <br /> a Business Telephone No. <br /> -Contractor Licence No. <br /> LApplicants Name (Print) Title ��/7?t<'fL— Date_ �_f?`�y +�• <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 l_ <br /> Description(Make/Yr.,Color) II <br /> I. Serial No. CAL. License No. CAL. Licc,se Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> i Equipment Parking Address it <br /> i 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored jl <br /> 3. ❑ PERCOLATION TEST II <br /> i R.S. or R.C.E. Name I� R.S. or R.C.E. No. <br /> r <br /> Test Location it Test Date/Time <br /> 4. ❑ SANITATION PERMIT lI <br /> Job Address/Location <br /> i Owner � Address S <br /> f ❑ SEPTIC TANK ❑ CESSPOIOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 19 REPAIR. ❑ OTHER_,._ <br /> 5. ❑ CHEMICAL TOILETS For'July 1,-June 30, 19 <br /> Type Construction II Disposal Site <br /> No. of Units 'IC Equipment Storage/Cleaning Location(s) <br /> k ' <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> F Plant Location <br /> Plant Capacity II No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq.ilFt., ❑ 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 /> i ordinances, state laws and rules and regulations of the San Joaquin Local Health District. <br /> ? APPLICANT'S SIGNATUR I� <br /> �u <br /> IIpIIIII 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 /> REMIT <br /> it <br /> BASE 11 <br /> II EXPLANATION <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> _ DATE DATE REMITTED AMOUNT <br /> FEE !erS;, 7— 79 �QD <br /> LESS :II <br /> PRORATION I. <br /> PLUS <br /> PENALTY II it <br /> ff OTHERS <br /> i !)OTHER ! - <br /> Received y D C Receipt No. <br /> Prib No. ssuanc Date Mailed Deliver d <br /> k" 12L/14 <br /> APPLICANT—RETURN ALL 1IES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601, ;HAZELTON AVE.'P.O.Box 2009 STOC ON,GA 5201 <br /> 5 <br /> I 4- <br />