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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION79 ,� <br /> _ <br /> P OA _ �.; . <br /> (For Non-Transferable, Revocable, and Sus endable) SEPTAG <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE — -- <br /> Applicatio a e arry on busi a in the jurisdictional area of the San Joaquin Local Healt D,s riot <br /> ,,Business Name DBA Address <br /> z Owner Address <br /> a <br /> w='0Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. f Emergency Telephone No. <br /> a �^ <br /> Contractor Licence No. 71 en <br /> Applicants Name (Print) e• Title - `� — Date �- <br /> Please check Applicable Category (1-7) and Fill in the Reqwred 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 /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> r R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 11 SANITATION PERMIT <br /> 04 <br /> It Job Address/ ation V727 <br /> caner Address <br /> SEPTIC TANK .CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> ERMANENT © TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -J e 30, 191 <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 /> p Operator Name Where Certified <br /> Plant Location <br /> I Plant Capacity No. Units Served <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> k ' <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 regul of the San JoaquinOcal Health District. <br /> APPLICANT'S SIGNATURE X <br /> r <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 <br /> ID <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt Na Permit No. -- 1 suance Date Mailed Delivered _ <br /> APPLICANT�RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009-. Ofi;CA 95201. <br />