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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .. APPLICATION <br /> (For Non-Transterable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> Application is ereby pade to carry n business in the jurisdictional area of the San Joaquin Local Health District <br /> ,F BusinessName (DBA) Address c <br /> a Owner Address AJ 7 C`' <br /> Firm Partners, Addresses and Telephone Numbers �dt(J.42 <br /> aBusiness Telephone No. 3�¢!Q�/ �� Emergency Telephone No.�S.e/,s� <br /> Contractor Licence No. <br /> Applicants Nan AW Title dW I E- Date <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) <br /> Serial No. CAL. License No. CAI_. License Renewal 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. Name R. r R.C.E. No. <br /> Test Location Test a/Ti <br /> 4. ❑ SANITATION PERMIT � <br /> Job Address/Locati n !1 3 <br /> Owner� 0'� Addr <br /> SEPTIC TANK ❑ CESSPOOL ��ACHIAGID ❑ EPAGE PIT ❑ PACKAGE2LAN®ERMANENT ❑ TEMPORARY I� NEW ❑ EPAER ❑ O5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19Type Construction Dite <br /> No. of Units Equipment Stoning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name here Certified <br /> Plant Location <br /> Plant Capacity���Ce o c� No. Units Serve <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 4ore Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. y <br /> f" <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, d rules <br /> and regulationsofthe Sari Local Health District. ` <br /> APPLICANT'S SIGNATURE X s2 j <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUACLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT pUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - ''rte <br /> Received by clate I Receipt No. Permit No. Issuance Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON .O.Boa 2009 STOCKTO4,,CA 952�01_ �_ <br />