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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION P, <br /> .,(For Non-Transferable, Revocable, and Suspendable) ; <br /> ;I ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> l LIQUID WASTE <br /> Applicatio�'sb}�ereby�r1a� to car n b si ess in t e urisdictional area of the S Joaqui LOCIHealth District <br /> rBusiness Na a (DBA) . 4r-11�61le �d� Address 158j(�lv�1l <br /> aOwner /►I. C +t�a� Address I <br /> �.Firm Partners, Addresses and TWY� e Numbers (� <br /> a Business Telephone No. w C's Numbers <br /> Telephone No. <br /> Contractor Licence No. 2.y3`71$ I <br /> � <br /> Applicants Name (Print) T - C'j'A�rolal Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information q <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. CAL. Li=3e Renewal No. <br /> i <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD II <br /> M <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST y <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location ;I Test Date/Time N <br /> 4. ❑ SANITATION PERMI r <br /> Job Address o tion Lout~ Ye /�iT�e► �'4 N <br /> Owner W©WOT LAG Cle Address <br /> 0 SEPTIC TANK ❑ CESSPOOL ;0 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 0 NEW ❑ REPAIR ❑ OTHER ic; <br /> S. ❑ 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�. r <br /> 7. 0 LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i! 1 <br /> I hereby certify that I have prepared this application and that a work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and Lules and reg�ations he San J in Local Health District. <br /> APPLICANT'S SIGNATURE.. <br /> a <br /> FOR DEPARTMENT USE ONLY - <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT APER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> � REMIT <br /> BASE. y EXPLANATION BILLING REMITTANCE $DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS ` V <br /> PRORATION t` <br /> PLUS <br /> PENALTY <br /> OTHER f <br /> „ <br /> OTHER <br /> i <br /> 5 13 7 <br /> Received by _ DateReceipt No. Permit No. - - Issuance Date Mailed eNv ed <br /> -APPLICANT—RETURN ALL-COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box.2009 STO TO 01- <br />