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( Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F APPLICATION <br /> I (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> r LIQUID WASTE <br /> F Applicati is hereby ma to carry on business in the'urisdictional area of the San Joaquin L��22cal Health District <br /> H business (DBA) _ � C!d .E l.�1C'E" Address- <br /> Name <br /> a Owner .0 Address 1745. �� ,C�E�®�f'T <br /> Firm Partners, Addresses and Telephone Numbers <br /> Q, Business Telephone No. �� 6 w <br /> a P Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) "* Title �ST Date / 9 <br /> Please check Applicable Category(1-7)and Fill in the Required Information 01 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 `' Disposal Sites I <br /> Description(Make/Yr., Color) <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 X <br /> No. of Vehicles Stored Q <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. 4 <br /> Test Location Test Date/Time Q <br /> 4. )9 SANITATION PERMIT <br /> Job Address/Location f <br /> Owner•4R f+;'C A/C i 11744,E& Address /.2 <br /> (ASEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER } <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site — <br /> II <br /> No..of Units Equipment Storage/Cleaning Location(s) f <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ' <br /> Operator Name Where Certified j <br /> Plant Location I <br /> Plant Capacity I 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 <br /> is <br /> r' _ 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, a ules and regulations of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> •F <br /> i4 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 .❑ July f &Received By Juiy 31 <br /> REMIT <br /> 1 BASE EXPLANATION BILLING REMITTANCE $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT i <br /> FEE <br /> t� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHERr <br /> OTHER ; <br /> i <br /> Received by Date Receipt No. - Permit No Issuance ate - Mailed Delivered ) <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.Bot 20 STO K CA 9 201 <br />