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(Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE � <br /> LIQUID WASTE <br /> Application is hereby made to carry on business In the furisdlctional area of theAan Joaquin Local Health Distract moo. <br /> �Business Name (DBA)"- 47 l 5 L Z' t s 4 <br /> � ,_ -�� z � Address, - <br /> z Owner.E.. '*1„ .9K. �.IL Address ,g'; _C.0,,,4 <br /> { <br /> Firm Partners, Addresses rrands Telephone Numbers <br /> a Business Telephone No. � �6 - -_-_ Emergency Telephone No. <br /> Contractor Licence No. ..5 " _ <br /> L Applicants Name (Print) . & Title _ck !cY Pt-, 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 .r <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored i <br /> No. of'Chemical Toilets Stored <br /> 3. 13.PERCOLATION TEST it <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑'SANITATION PERMIT <br /> Job Address/Location ` -' 3 0 ". �- <br /> Owneir kkt tNAIA Address E <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD t, vpSEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY E] NEW REPAIR 13 OTHER <br /> 5. ❑'CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type.Construction Disposal Site <br /> i <br /> No. of Units Equipment Storage/Cleaning Location(s) f <br /> 6. El 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 /> Ei <br /> I hereby cerfify-that I have prepared this application and that the work will be done in accordance with San Joaquin County I <br /> ordinances, state la and rules arfd regulation`s of the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE: -- €; ' " -L <br /> E: <br /> IJ <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 /> l� BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT I <br /> FEE f e- , <br /> MESS <br /> �-PRORATION ' <br /> iPLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - I Dae Receipt No. Permit No. Issuance Date Mailed, „E1eli Yad�- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTOI__95201 <br />