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± Applications Will 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 <br /> LIQUID WASTE <br /> F Application is hereby made to carry on usiness in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) dtd Address <br /> a Owner Address <br /> I 9 Firm Partners, Addresses MTeoneNumbersa Business Telephone No. D Emergency Telephone No. <br /> J Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) y <br /> Serial;No. "' CAL License No. """"""'CA t=ip Esse Renewal No. <br /> ii <br /> Capacity Gal., Weights & Measures No. <br /> i Equipment Parking Address <br /> 2. ❑ PUMPER YARD .t <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored l <br /> No. of Chemical Toilets Stored'. "�'� <br /> 3. ❑ PERCOLATION TEST zCbw <br /> k R.S. or R.C.E. Name x i "� *� R.S'or R.C.E. No. i 5 <br /> I <br /> Te <br /> s Location - Test Date/Time <br /> II 4. ASANI ATION PERMIT ; <br /> Job Address/Location <br /> Owner Z Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 3;<ILEACHING FIELD AGE-PIT„ ..❑,.PACKAGE PLAN! <br /> ❑ PERMANENT ❑ TEMPORARY,- ❑ NEW REPAI ❑ OTHER <br /> 5. 13 CHEMICAL TOILETS For July 1;.-June 30, 19 <br /> Type Construction l' I., Disposal Site e I <br /> No. of Units= " -k <br /> tEquipment.Storage/Cleaning Location(s) t <br /> 6. ❑ PACKAGE TREATMENT PLANT'.For July 1r-'.-June 30,;19 �f 9 <br /> Operator Name �" Where Certified4_ <br /> Plant Location <br /> . r <br /> �v .I <br /> Plant Capacity s � No. Units SenvedR' <br /> 7. ❑ LAUNDRY Foi 1, -June 30, 19 7 ~ <br /> SIZE: ❑ Less Than 1+,000 Sq. Ft., © More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ', <br /> 42Y}� w <br /> I hereby certify that I have prepared this-application and that.ahe work will be d"ne in accordance with San Joaquin County <br /> ordinances,'state laws, and i and regulations of the San Joaquin L al Health District: <br /> APPLICANT'S SIGNATURE XI" # " <br /> c FOR DEPARTMENT USE ONLY a ) <br /> k <br /> Fee Is Rue: ❑ ANNUALLY" ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received 8y January 31 j ❑ July 1 &Received By Ju6y 31 <br /> REMIT <br /> %)BASE .� EXPLANATION BILLING REMITTANCE $ z-`" AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION" <br /> 3 <br /> PLUS <br /> PENALTY T k <br /> OTHER <br /> OTHER <br /> Received by I to Receipt No. Permit No. Issuance DatT3 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES1601 E.HAZELTON AVE.,P.O.Boz 2049 STOCK To ,GA 9" 91 <br /> T <br />