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Applications Will Be Processed When Submitted Properly Completed. BeSureTosign IneAppncauvn. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ' hereby de to car n busi ess i the j dictional area of the San Joaquin Local Health District <br /> sn Business Name A ' Address �� <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL yr Emergency Telephone No. <br /> 0.a Business Telephone No. _ <br /> Contractor Licence No. �r <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required nformation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) r <br /> Serial No. CAL. License No. CAL, License 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 Dation Test Date/Time <br /> q, lE7 SANITATION PERMIT <br /> Job Address Loca 'on e <br /> Owner Address <br /> 1:1 SEPTIC TANK CESSPOOL ❑ LEACHING FIELD 9S EPAGE PIT ❑ PACKAGE PL NT T} <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW P REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �1 <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 <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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, andyps and regulation the an 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 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED MOUNT— <br /> FEE S Q - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> 201 <br /> APPLICANT--RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., Box 21109 t O�KT4O1+1,(A Sb) <br />