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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE Y <br /> LIQUID WASTE -Z <br /> Applicati hereby a to carry on business in the jurisdictional area of the San Joa ui n L al Healt Distri t .,rte <br /> y Business Name (DBA} O f-''PCS Address r � <br /> aOwner om G Address`��� �–r 7— <br /> j Firm Partners, Addresses and T ep one Nu bels <br /> 0. Business Telephone No. C� <br /> a Emergency Telephone No, <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title :25-5r, Date "oz <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. CAL. Licr.nse 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 t <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. X SANITATION PERMIT <br /> Job Address/Locatio ��SCC� Qt',�v .- C <br /> ��� <br /> Owner Address <br /> SEPTIC TANK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT 1 <br /> rPERMANENT ❑ TEMPORARY ;NEW ❑ REPAIR ❑ OTHER <br /> 1l CHEMICAL TOILETS For July 1, -June 30, 19 n' <br /> Type Construction Disposal Site A <br /> No. of Units Equipment Storage/Cleaning Location(s) to <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 4 <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 ed this application and th the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d rules a d regulations f the San apin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Yea, FOR DEPARTMENT USE ONLY <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT uu PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JWY 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS Z <br /> PRORATION <br /> PLUS <br /> PENALTY ,1�1 <br /> OTHER V <br /> OTHER <br /> RAA a <br /> Received by Date Receipt No. Perrhit No Issuance Date Mailed Delive d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC TON,C. 95281 r� <br /> C_lf� <br />