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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> t LIQUID WASTE . <br /> Application is hereby made to carry on business in the juriVjctionatArea of the San Joaquin Local Health District <br /> rBusiness N (DBA) " Address <br /> U) ��y --� Address <br /> z Owner <br /> a <br /> Firm Partners, Addresses and Tele&honeiNumbers �. <br /> aBusiness Telephone No. L� ) Emergency Telephone No. <br /> Contractor Licence No.-j'i <br /> Applicants Name (Print) �-'�— �- Title ",'`'1 � � Date t <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 /> l Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> t Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD.. . <br /> For July 1, June 30, 19 G <br /> I r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I T <br /> 3. ❑ PERCOLATION TEST C <br /> i RSor RC <br /> R.S. or R.C.E. Name . . . .E.'No. <br /> _ V <br /> Test Location Test Date/Time <br /> 4. 1cr-SANITATION PERMIT <br /> Job Address/ cation �� .��� �� C <br /> fff_ Owner ��' `-- - Address 6 <br /> 'SEPTIC TANK C1 CESSPOOL BLEACHING FIELD ❑ SEEPAGE-PIT ❑.PACKAGE PL T <br /> PERMANENT ❑ TEMPORARY ❑ NEW 11REPAIR 11 OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 G <br /> Type Construction Disposal Site. <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT , For July 1, -June 30,.19- <br /> Operator Name Where Certified <br /> Plant Location - <br /> Plant Capacity I No. Units- <br /> .Served <br /> 7. ❑ LAUNDRY For July 1, -June 36, 19 <br /> k SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. F <br /> i �d�i N/j Jr_ TAl&k �c �- x`'79 <br /> fs 9_j-1- 7? <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, a u sand regula ' sof the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> IT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE + DATE REMITTED AMOUNT f� <br /> l FEE <br /> OF <br /> LESS <br /> PRORATION - <br /> PLUS *' <br /> PENALTY <br /> 1 OTHER <br /> OTHER <br /> ceived by Date - Receipt No. 'Permit N Issuance ate Mailed D d <br /> APPLICANT—RETURN-ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE:,P.O.Box 2D09 - S CKTON,CA-9520 <br /> - -i <br />