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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 /> Applicatio i hereby made to carry on bu iness in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name BA) Address <br /> aOwner Address . <br /> J Firm Partners, Addresses and Tele one Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> .J Contractor Licence No. <br /> Applicants Name (Print) 0_0 Title � y� Date <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) <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 /> CNo of Chemical Toilets Stored <br /> ` 3. ❑ PERCOLATION TEST <br /> kI R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. AS PERMI 1 <br /> I Job Addres Lo tion <br /> a <br /> or 17 <br /> Owner Address <br /> ❑SEPTIC TANK ❑ CESSPO L LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> r 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 Where Certified <br /> Plant Location <br /> Plant Capacity . No. Units Served <br /> ! 7. ❑ LAUNDRY For July 1, -June 30, 19 f <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., IT More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> y� 24 <br /> 7 7'5' d fc s,i <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, aDd4ul d regulations of the S n Joaquin ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> �v <br /> FOR DEPARTMENT USE ONLY / <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Ja uary 1 eceived By January 31 ❑ July I &Received By July 31 <br /> BILLING REMITT E $ ., REMIT <br /> -`'BASE EXPLANATION DATE T REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> k FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received IYy fbate _Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT!$ERVICE$ 1601 E.HAZELTON AVE.,P.O.Box 2009 "ST6CKTON;CA 95201 <br /> t - - <br />