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Applications Will Be Processed When Submitted ProperlyCompletetl. be sure tualyri him �rr ��• <br />.� <br /> APPLICATION <br /> W w (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> On Business Name (DBA) Address Y <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Teleph �Numbers <br /> a Business Telephone No. r •� a Emergency Telephone No. <br /> Contractor Licence No. Title k_�Date '- <br /> Applicants Name (Print) <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. CAL. License No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD t -` <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> Tes Location Test Date/Time - <br /> 4. SANITATION PER IT r <br /> Job Address/ oration 471 <br /> fop G <br /> Owner P — Address <br /> �y �r SEEPAGE PIT ❑ PACKAGE PLANT Qr <br /> N SEPTIC TANK ❑ CESSPOOL 4a LEACHING FIELD ❑ ❑ OTHER <br /> PERMANENT 13TEMPORARY O(NEW REPAIR <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 <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 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, and rules and regulations of the San Joaquin Loc Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> i, <br /> ❑ PER SITE El ❑ January 1 8 Received 8y January 31 July t R Received EB�ylTuly 31 <br /> Fee Is Dile: El ANNUALLY PER UNIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATEREMITTEDREMITTED AMOUNT <br /> FEE <br /> `7sR �~ r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> '77- 9 ? ' <br /> Received by <br /> Date Receipt No- Permit No Issuance ate Mailed "DLII e <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.B 0 S KTO A 95201 ( ' <br />