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•,, -=Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I ' APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i here made to carry on lqusiness in the jurisdictional area of the San Jo quin Local H alth District ' <br /> rn Business Name DBA 'il l ?'�. - �° p <br /> (DBA) Address �- <br /> aOwner aPK Address R <br /> 2 Firm Partners, Addresses and Telephone Numbers f r <br /> IL <br /> Business Telephone No. Emergency Telephone No. _ <br /> Contractor Licence No. 4--e P" <br /> L Applicants Name (Print) Title Qf./&1 " Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ForJuly 1, June 30, 19 E Disposal Sites ` <br /> Description(Make/Yr., Color) us <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. 911 <br /> PUMPER YARD <br /> ForJuly 1, June 30, 19 <br /> No; of Vehicles Stored Q <br /> No.!of Chemical Toilets Stored l("+ <br /> 3. PERCOLATION TEST <br /> R.S.j-or R.C.E. Name �.` R.S. or R.G.E. No. <br /> :;I. <br /> Test Location Test Date/Time <br /> 4. t SANITATION PERMIT J j <br /> Jobb Address/Location t� l e G <br /> 1 <br /> lour �Q ►1��t�' � Address �`� FJ/ 4010 1Z C <br /> caner _ <br /> (SEPTIC TANK ❑ CESSPOOL X LEACHING FIELD" ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> )0)0 PERMANENT ❑ TEMPORARY ;� NEW ❑ REPAIR ❑ OTHER r <br /> :,PERMANENT <br /> 5. -E] CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site �p <br /> Nolof Units Equipment Storage/Cleaning Location(s) h <br /> 6. °I❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> ZPlnt Location <br /> lsjt Capacity No. Units Served <br /> 7. LAUNDRY LAUNDRY For July 1, -June 30, 19 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Tharl 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> n <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 rules and regulations of the Joaquin Local Health District. iE <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY -❑ PER UNIT C PER SITE ❑ EACH ❑ Januar 1 &Received B Januar 31 <br /> January y y EJ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> I . PLUS <br /> PENALTY <br /> : I OTHER <br /> OTHER <br /> Received by Datet Receipt No. Permit No, Issuance Date Mailed Deliv ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2000 -STO KTO 01 �"' <br />