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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. h f- <br /> ` APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> r Application is by made to c ryon busi ss in the ju is 'onal area of the Sa oaquin Local Health District ; <br /> rn Business Name (D A) Address <br /> Ill <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. 0—:6" <br /> Emergency Telephone No. <br /> Contractor Licence No. S <br /> L Applicants Name (Print) Title Date C2 4 <br /> Please check Applicable Category (1-7)and Fi11–in-the Rewired 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. f CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address .. Fl <br /> 2. ❑ PUMPER YARD I f <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored -I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name. R.S. or R.C.E. No. <br /> Test LL ation Test Date/Time <br /> 4. IJ SANITATION PERMIT <br /> Job Address/1,jaCaticin <br /> I <br /> ,Ow�n Addr ss <br /> PTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> �IPERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 i <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 3Q, 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. f <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 actor` ante with San Joaquin County <br /> ordinances, state Paws, and rules and egulations of the n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT uSENI <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jan &Received By January 31 ❑ July 1 &Received By July 31 t <br /> BILLING REM ANd REMIT f <br /> BASE EXPLANATION $DATE E REMITTED <br /> AMOUNT DUE CHECKED <br /> T <br /> D-� AMOUNT <br /> FEEN <br /> LESS C� <br /> PRORATION I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date - Receipt Na Permit No. Issuance D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES1601 E.HAZELTON AVE.,P.O.Bow 2009STOCKT6N,CA 95201 4 <br />