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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) R <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i reby made t car 0s in s i . e j 'sdictional area of the San Joaquin LQcal Health Dista t <br /> yBusiness Name (DBA) Address <br /> z Owner AddressT -=-- <br /> R <br /> a Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. cg-S Emergency Telephone No. <br /> Contractor Licence No. 32 <br /> LApplicants Name (Print) Title Date — Z <br /> Please check Applicable Category (1-7)an Fill i e Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ilv <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parkfng-Address __ f <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. Name R.S. or R.C.E. No. <br /> Test Lo Ion Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job AddreCation <br /> Owner ss/L Address y+p <br /> ❑ SEPTIC TANK © 9fSSPOOL ❑ LEACHING FIELDSEEP PIT C1 PACKAGE PLANT <br /> 11 PERMANENT E] TEMPORARY ❑ NEW PAIR ❑ OTHER <br /> 5. ❑ 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 <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: <br /> 0, 19SIZE: ❑ 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 rul nd regulations of the San Joaquin Local Health District. <br /> Af r <br /> APPLICANT'S SIGNATURE X <br /> ..r <br /> FOR DEPARTMENT USE ONLY+ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING. REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE flEMITTEU AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S o <br /> LESS 1 <br /> PRORATION <br /> PLUS F <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuanc Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST CKTON,CA 95201 <br />�. t�eved ?PA la z <br />