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t Applications Will Be Processed When Submitted ProperlyCompleted. taesure Ioalign rirC••I+Nvl.,o.,..,,• <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ereby made carry on.bb siness in V jurisdictional area of the Sa Joaqujn Local Health DJist�r t <br /> NBusiness ��� Address << �� J <br /> a Owner <br /> Address <br /> Firm Partners, Addresses and Telephone Numbos <br /> aBusiness Telephone No. 3« © Emergency Telephone No. C� <br /> Contractor Licence No, 3 F Z- rte[? —`J <br /> i Date - y <br /> LApplicants Name (Print) Title <br /> Please check Applicable Category (1-7)and Fill in the Required formation <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. Licw,se 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.C.E. Name R.S. or R.C.E. No. <br /> n Test Date/Time <br /> Test Loc <br /> 4. 931SANITATION PERMIT <br /> Job Address/Location y A/ a �� <br /> d 2F l icy Address 45-V13 <br /> Owner El PACKAGE PLANT <br /> 11 SEPTIC TANK ❑ ESSPOOL LEACHING FIELD <br /> ❑ PERMANENT 13 TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location y <br /> PNo. Units Served <br /> Plant Capacity <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 /> application and that the work will be don i cc ordance with San Joaquin County <br /> I hereby certify that I have prepared this app , <br /> ordinances, state laws, and rul vnd regulations of a San Joaquin Local Health Dias t. <br /> APPLICANT'S SIGNATURE X `0 <br /> FOR DEPARTMENT USE <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH J ary 1 &Received By January 31 ❑ July 1 &ReceiveRdEBAyI July 31 <br /> BASE - EXPLANATION BILLING IT NCE $ AMOUNT DUE CHECKED <br /> DATE E REWTTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed r d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALT14 PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STT KTON,C 5201 r <br />