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PP1 "-_ <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> (z p �? - APPLICATION 2" C�1O P rh <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> �Z t ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Nar lj6 DBA) F Addres �� <br /> i Owner `✓�1 6' R Address <br /> Firm Partners, Addresses and Telephone Numbers !t le- V t . 6 C <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print, *y rle Title = ,' 2-4- 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 �1 <br /> Description(Make/Yr., Color) — n <br /> Serial No. CAL. License No. _ CAL. Liccnse 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 /> Test 6ffation Test Date/Time <br /> 4. ANITATION PERMIT1 <br /> Job Address/L at' n N s <br /> Owner AW P U Address / 4,3 <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER G <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) o <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 (� <br /> Operator Name Where Certified <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 prep red this applicatio and th a work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r les d r ulations of he Sa Joa in Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE �� <br /> LESS <br /> PRORATION <br /> PLUS � <br /> PENALTY rJ I A// <br /> OTHER O /� <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is5 ance D to Mailed IDeliver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ,STOC ON,CA 9 201 <br />