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Applications Will Be Processed When Submitted Properly Completed. BeSureTo <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendabie) SEPTAGE -- <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is herebmade to carry on business in jurisdictional area sstie®n JJo�nLocal Health District <br /> Address <br /> � I <br /> mrBusiness Name (DBA) <br /> Address <br /> a Owner <br /> j Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. �' A Emergency Telephone No:— <br /> a <br /> Contractor Licence No. " -•-R <br /> • l�t..�. Title [-i��i�a�'Q �` Date l <br /> �Applicants Name (Print) �. <br /> Please check Applicable Category (1-7)and-Fill In the Required Information t .. n• t # <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, ,-`' June 30, 19 - CC. - :Disposal Sites - <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> I, Serial No. CAL. Ueense-No. <br /> Capacity Gal;,; <br /> Weights 8 Measue iVo -` �# <br /> Equipment Parking Address t ' <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19' t <br /> t <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. [1 PERCOLATION TEST-. I <br /> i R.S. or R.C.E:No. <br /> R.S. or R.C.E. Name ... <br /> Test Date/Time, Y� .�r, '• <br /> Test Location J 9 <br /> t <br /> 4 4. SANITATION PERMIT <br /> ® <br /> Job Address/Location ' r •"" <br /> t <br /> Ow" r ��' Address ?s.. <br /> © SEPTIC TANK ❑ CESSPOOL ED-LEACHING FIELD-•'D SEEPAGE-PIT,Q,.PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ] O N.EW 1] REPAIR . ❑ OTHER <br /> I ` <br /> 5. <br /> CHEMICAL"TOILETS For July 1,-June 30, 19�_Z__f <br /> -Disposal Site <br /> Type Construction ) - <br /> R ¢ <br /> No. of Units ;Equipmerii Storage/Cleaning Location(s) I <br /> B. ❑ PACKAGE TREATMENT PLANT rFor July 1, -June 30, 19 <br /> . —Where,Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No.Units Served <br /> # 1 ` <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. t <br /> 'A <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - I <br /> 49 <br /> I hereby certify that I Cav prepared this.applica Itlt cn and that th,".,5rk be done ih'accordance with San Joaquin County <br /> ordinances, state law an r Tes and recitations of Ili Joaglflla'.Local Health District: } <br /> q �-- - <br /> APPLICANT'S SIGNATURE 7( <br /> _ FOR DEPARTMENT USE,ONLY <br /> # }� •._ . <br /> Fee Is Due' ❑ ANNUALLY ❑ PER UNIT f ❑ PER SITE ❑NEAGH r ❑ January 1 &Received By January 31 ❑ July 1 Received By July 31 <br /> _ -- -� REMIT t <br /> ` BILLING REMITTANCE $ AMOUNT DUE CHECKED ! <br /> BASE EXPLANATION DATE - DATE, REMITTED- AMOUNT <br /> .r <br /> FEE <br /> LESS �U <br /> PRORATION �. <br /> PLUS <br /> PENALTY . <br /> OTHER 3 t <br /> n L OTHER ,�y, - ;: ` .r, ; 'E .r .. £ :. .. � <br /> 41. <br /> issuanc Mailed, w..1]elivered <br /> Received by Date Receipt No- Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: EMVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HA <br /> ZELTON AVE..P.O.Box 2009 5TOGKTON,GA 93201 <br />