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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ' APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) J <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE t <br /> Applicatiis hgeby m e to carry on busine 1p the jurisdictional area of the San Joaquin Local Health District~ <br /> f <br /> ,, Business N me (DBA) l� l'� Address `��.-. Sr �/�� / <br /> f 4 Owner �' Address ��d� �vf� <br /> Firm Partners, Addresses and Iqpa Nuns ers <br /> _h o0. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. . <br /> LApplicants 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) <br /> For July 1, R June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) . <br /> Serial No. CAL. License No, CAL. Licc,ase Rii 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 /> Test Location t I Test Date/Time wt,f <br /> 4. X SANITATION PERMIT �_ o <br /> Job Ad ss/Locati <br /> j Owner on <br /> p �r Address1 <br /> ❑ SEPTIC TANK. ElCESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PL NT <br /> PERMANENT ❑ TEMPORARY =❑ NEWC. <br /> REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 C. <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) 4C1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> F Operator Name V1, Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 }I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> i ❑ 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 <br /> ordinances, state law , an ru sand regulations of the 59n Joaquin Local He th District. <br /> APPLICANT'S SIGNATURE X I <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT I;[s,�.PER SITE %❑ EACH ❑ January 1 &Received ay January 31 - ❑ ,July 1 $,Received By July 31 <br /> +i <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS / <br /> PRORATION <br /> PLUS s !!! ✓ - <br /> PENALTY ` <br /> OTHER <br /> 1 4 <br /> OTHER <br /> A4- 7L" <br /> Receivetl-by Date Receipt No. Permit No. Issuance Date � Mailed d'APPLICANT-=RETUAN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1Ili E..HAZELTON AYEfP.O.Bax 2009TON,CA 952 F <br />