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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. � � <br /> 4 W APPLICATION 'V'� <br /> (For Non-Transferable, Revocable, and Suspendable) � M / /e <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE Q <br /> Applicatio is hereby rpade to carry on busi le4ss2 the jurisdictional area of the San Joa uin Local Health District <br /> Business IVa (DBA) Address19 , <br /> Business <br /> aOwner Addresst <br /> Firm Partners, Addresses and Telephone Numbers <br /> 5. Business Telephone No. .32-ef =S�! ���� _ Emergency Telephone No, <br /> Contractor Licence No. 2 <br /> L Applicants Name (Print) 1_1 Title f¢.d Date g -10e <br /> Please check Applicable Category (1-7) and Fill in the Require 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 /> l No. of Vehicles Stored <br /> No. of Chemical Toilets Stored.. <br /> 3. ❑ PERCOLATION TEST U) <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. _P4 <br /> Test L cation Test Date/Time <br /> 4. SANITATION PERMIT �a <br /> Job Address/Locon es <br /> Ow r ' Add4, 1 <br /> OSEPT,,TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 11 NEW ®REPAIR ❑ OTHER <br /> f <br /> S. ❑ 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 F <br /> Operator Name Where Certified <br /> f <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. r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> T`4- 5i <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, and rule d regulations of the San Joaquin Local Health District. <br /> k <br /> APPLICANT'S SIGNATURE X <br /> t <br /> a <br /> FOR DEPARTMENT USE ON <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ Jan ry 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT I <br /> BASE EXPLANATION BILLING H ANCE $ AMOUNT DUE CHECKED <br /> DATE A E REMITTED AMOUNT <br /> FEE �� C✓ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER VIV <br /> OTHER ., <br /> R APPL CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEpMITlSERYICES�� t 1TO"�AY���O.ja�ox�2009 STOGKr ON,CA 5201 <br />