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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _ APPLICAT-ION , 4 <br /> �' (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE t <br /> LIQUID WASTE <br /> Application is hereby ade to carry ori bus' ess in the jurisdictional area of the an Joa uin Local Health District <br /> F Business Name (DBA)—L. 5 Address Q 3e1 ) <br /> 4 Owner Address <br /> 7 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 4,7 - Emergency Telephone No. i <br /> Contractor Licence No. _ <br /> Applicants Name (Print) Title. Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Y <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) - <br /> Serial No. CAL. License No. CAL. L(c,.nse 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.S. or R.G.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 0 SANITATION PERMIT JI. <br /> Job Address/Location __W/ �X!!y��y -- <br /> Owner Address 111 ZA_iP ,Y <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD W ,,E9aA E i ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ISI REPAIR OTHER -SCA 8/X 12, <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site th <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -Juane 30, 19 I <br /> Operator Name Where Certified <br /> Plant Location <br /> PlantCapacity ' No. Units Served 3 <br /> 7. ❑ 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 /> ) <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 rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 73 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> - <br /> BASE- EXPLANATION BILLING REMITTANCE $ AMOUNT DUE- CHECKED { <br /> DATE DATE REMITTED AMOUNT 7f�J <br /> FEE � � � <br />! LESS ; <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER -, - <br /> OTHER <br /> � 1v`Llo <br /> Received by Date - Receipt No. Permit No. u ce Date Mailed ewer - <br /> APPLICANT-RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE P.O.-Bar 2009 STOCK ON,CA 9 1 <br />