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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION L <br /> s (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE O� <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA _;?Pd R6a? _',,# lJtC_477 Address �� <br /> �g7 <br /> a Owner F Address.�� <br /> Firm Partners, Addresses and Tele hone Numbers - <br /> aa Business Telephone No. S " <br /> a Emergency Telephone No. <br /> A Contractor Licence No. <br /> Applicants Name (Print) / jam Title Date d ' <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) G <br /> Serial No, CAL. License No. CAL. License Renewal No. + <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address J <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 r <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 Location Test Date/Time <br /> 4. you SANITATION PERMIT <br /> Job Addre Location Df <br /> Owner >� C"l Address-9'24/ �� f 54 <br /> iCai/ f"�z yca <br /> ❑ SEPTIC TANK -E] CESSPOOL X LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW Rr REPAIR ❑ OTHER <br /> 5. ❑ 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 /> r <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30,"l 9 ' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft" t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 ru and regulations of the San J, gLin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> ra FOR DEPARTMENT USE ONLY <br /> Fee Is Due: El ANNUALLY © PER UNIT la PER SITE ❑ EACH ❑January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> �. REMIT <br /> DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> Received by Date Receipt No. Permit No. Is uance Date Mailed Deli ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST CKTON, A 95241 <br /> « . <br />