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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> I "'' (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> 1 LIQUID WASTE p <br /> Application ' hereby mai to carryo busi es�jin th risIictional area of the San Joaquin Local Health Di rict <br /> s rn Business Name ( ) C ca ' Address <br /> ROwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> 1 a Business Telephone No. 3 15-10 <br /> S <br /> a Emergency Telephone No. <br /> Contractor Licence No. Z_2_0 <br /> L Applicants Name (Print) t Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required 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. GAL. Licc;se Renewal No. <br /> Capacity Gal., Weights & Measures No. y <br /> Equipment Parking Address <br /> ' 2. ❑ PUMPER YARD (� <br /> .For July 1, June 30, 19 S <br /> k No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> I 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> I Test L7ation Test Date/Time <br /> 4. 1=J SANITATION PERMIT <br /> Job Address/Location S <br /> O er Address <br /> ,��EPTIC TANK CESSPOOL EACHWG FIELD SEEPAGE PIT ❑ PA AGE PLANT <br /> LJ PERMANENT ❑ TEMPORARY :;v Address <br /> ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> f No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified T <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f <br /> ordinances, state laws, and r and regulations of t e San Joaquin Local Health District. <br /> . 1 <br /> i APPLICANT'S SIGNATURE X I <br /> 4 <br /> 4 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 /> iBILLING REMITTANCE $ REMIT S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED -' <br /> r <br /> FEE AMOUNT '1{ <br /> I � 'I y C_ <br /> LESS { <br /> PRORATION 4 <br /> PLUS ► <br /> PENALTY <br /> OTHER <br /> OTHER" <br /> —7 s <br />�- - Received by - Date Receipt No. Permit No. Issuance Date M17ailed "C52 APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HA�ZELTON AVE.,P.O.Box 2009STO <br />