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.a Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ) <br /> W APPLICATION `- <br /> _ (For Non-Transferable, Revocable, and Suspendable) ► <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i ereeby mad to carry o business' the j sdictional area of the Sarr,Joaquin Local Health District <br /> v;Business Name (DB } Address e- <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. S Emergency Telephone No. I <br /> Contractor Licence No. 8 �` <br /> Applicants Name(Print) = �-� Title ��S 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. CAL. 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.S. or R.C.E. No. _ <br /> Test Lo tion Test Date/Time <br /> 4. SANITATION PERMIT Qj <br /> Job Address/Location <br /> Ow r Address =SQA <br /> SEPTIC TANK ❑ CESSPOOL I- ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 93 NEW ❑ REPAIR ❑ OTHER <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 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4 <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules a gulations of the �quin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 17 PER UNIT 1K PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED s <br /> AMOUNT <br /> FEE S S <br /> LESS <br /> PRORATION , <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 5 <br /> Z rrt. <br />'t Received by Date Receipt No. ermNv. Issuance to Mailed .liver 1 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - SLC ON,CA 5241 <br /> / fie, 'A i <br />