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/\i . -I V I\ f I V- <br /> I Non-Transferable, Revocable, and Suspendable' <br /> _NVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio Is he b ade to car on bu ess in the rtsdictional area of th n uin L al alth net t� <br /> yBusiness Name (DBA) _ 1, J� Address �� q � � <br /> aOwner_ _._ - -_- _- - Address <br /> J Firm Partners, Addresses and Tee hone Numbers <br /> CL <br /> 5. Business Telephone No. _ - �� __- _ -_-..___ _. Emergency Telephone No. <br /> Contractor Licence No. 5 y <br /> L Applicants Name (Print) _- - -- --------- -- Title --5;�-T <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J <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 /> u <br /> 3. ❑ PERCOLATION TEST v <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. v <br /> Test ocation Test Date/Time <br /> 4. .SANITATION PERMIT <br /> Job Addre�//Location�`77� �2E-�fer /7r-E TOKT 14T F Ca �'`�• Address �� CEP ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARY NEW ❑ REPAIR OTHER A0,41N B6D <br /> ❑ CHEMICAL TOILETS For July 1, -June 30, 19--- <br /> Type <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 <br /> SIZE: 11Less Than 1,000 Sq. Ft., El More Than 1,000 Sq. Ft. <br /> C3 DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> fj <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, a9d rules and r gulati f the n 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 ❑ July 1 &Received By July 31 <br /> --- — --- -- —"— REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> -- <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS— — `- N R 1 <br /> PENALTY [� y <br /> OTHER- — <br /> OTHER <br /> Received 6y Date Receipt No Permit No Issua ce Date Mailed D iv <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOC ON,CA 911 <br />