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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> ,,. APPLICATION <br /> (For Non-Translerable, Revocable, and Suspendable) i <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> i <br /> Application is reb�made to rryn bust in the'ur' di t' nal area of the S oaqui Local Health District <br /> wBusiness Na & ddress a <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone umbers a(7 <br /> aBusiness Telephone No. 311,9 "lei a Emergency Telephone No. C j <br /> j Contractor Licence No. i <br /> LApplicants Name{Print) Title Date <br /> Please check.Applicable-Category (1-7)'and Fill in the Required nformation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites # <br /> Description(Make/Yr., Color) . . e <br /> Serial No, CAL. License No. CAL. Liccnse Rencwal No. <br /> i. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ori <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 cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> k Job Address/Loca ion <br /> Owner - Address < « (i•' <br /> ❑ SEPTIC TAN ❑ CESSPOOL J LEACHING FIELD ,.�/SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMAIIE ❑ TEMPORARY ❑ NEW l REPAIR 11 OTHER N <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 T Q <br /> Operator Name Where Certified [C,' <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 k' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> l ❑ 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-M h" San Joaquin ounty <br /> ordinances, state laws, and rand regulations of San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X / I I ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11ANNUALLY ❑ PER UNIT PER SITE El EAG ❑ Janua &Receiv /jan.ary_ 31 ❑ J y 1 &Received By July 31 <br /> BILLING REMITT E $ REMIT <br /> BASE EXPLANATION DATE D E &$&TTED AMO T DUE CHECKED <br /> AMOUNT <br /> FEE l✓ <br /> LESS �� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ' OTHER <br /> OTHER <br /> I. <br /> Received by Date- Receipt No. mit No. Issuance D to Mailrid %�eliverecl <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKT N,CA 95201 ���" <br />