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v Applications Will Be Pj* JsedWhen Submitted Properly Completed. tiesure Iosign rirc+�NN••ti�••� cps <br /> APPLICATION <br /> FEB 14 ��80 L4 <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE I <br /> SAN JQAQUI�i LOCAL LIQUID <br /> HEALTH PERMIT <br /> LIQUID WASTE r1 <br /> HEAl.T,ih D�ST%g R <br /> Appllcatl n Is ere a t carry on business in the jurisdictional area of theS,a�n_Joafqu_i�n ocal Health Di trict <br /> r Business Name (DBA) 7- Address�.L - <br /> z Owner <br /> Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 1 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title e Date�1 ' <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) CAL. License Renewal No. <br /> Serial No. CRL. License 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. No. W <br /> R.S. or R.C.E. Name <br /> Test Date/Time W <br /> Test Location to <br /> 4. ❑ SANITATION PERMIT <br /> Job Addre s/Locat' n <br /> Owner U Address <br /> C'SEPTIC TANK ❑ ESSPOOL 2 LEACHING FIELD ❑ SEEPAGE PIT 13 PACKAGE PLANT <br /> L1O PERMANENT ❑ TEMPORARY GVNEW ❑ REPAIR ❑ OTHER <br /> 4 <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 dl <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 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun y <br /> ordinances, state laws, an rules and regulatio of t e San Joa uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> ' v <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT lyPER SITE ❑ EACH ❑ January 1 &Recewed By January 31 ❑ Juiy 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION "DATE DATE REMITTED AMOUNT_ <br /> FEE <br /> LESS Can <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER >F't <br /> OTHER 5 <br /> Received by <br /> Date Receipt No. Permit o, Issuance Date Mailed etivere <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKY N,CA 9 <br /> APPLICANT—RETURN ALL COPIES TO: ETIVIRONMENTAL HEALTH PERMITlSERVICES ___ y <br />