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r i <br /> Applications Will Be Processed When Submitted Properly Completed. BeSure o Ig <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE ! <br /> �. ENVIRONMENTAL. HEALTH PERMIT <br /> LIQUID WASTE I" <br /> Application i reby made o carry on b iness in th 'uris 'ctional area of the San aquin Local Health District <br /> OF Business Name 04 7 <br /> (DBA) Address <br /> aOwner ddress <br /> 03-Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �! Emergency Telephone No. <br /> i <br /> -t Contractor Licence No. Z <br /> �Applicants Name (Print) <br /> Title Date <br /> Please check Applicable Category:(1-7) and Fill in the Require Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No: CAL. License No. <br /> V <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> I 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 " <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> i 3. ❑ PERCOLATION TEST <br /> i R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Dation Test Date/Time <br /> 4. � SANITATION PERMIT /J <br /> Job Address/Location 7 <br /> O�wn� 4 Address <br /> I LT SEPTIC TA ❑ CESSPOOL LEACHING FIELD R'SEEPAGE PIT PACKAGE PLANT 6' <br /> I ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> k 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <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 Where Certified <br /> I Operator Name <br /> Plant Location <br /> No, 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 /> I <br /> E , <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 rule d regulations �thSan 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 J &Received By January 31 ❑ July 1 &Receiv d By REMITuly 31 <br /> r <br /> BASE EXPLANATION BILLING REMITTANCE - $ AMOUNT DUE CHECKED \ <br /> DATE DATE REMITTED AMOUNT <br /> t <br /> � FEE � /I <br /> LESS V <br /> s PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No: issu nce vate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2004STOGKTO ,GA 95201 <br /> — <br />