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�-' Applications Will Be Processed When Submitted Properly Compieted. Be Sure To Sign The Application. <br /> APPLICATION <br /> w (For Non-Transferable, Revocable, and Susperidable) ` <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicationl�1 heerb ade�y on busi ess in the ju isdictional area of the ®Jo quip Local Health D' tr t <br /> ,F Business Name {DBA) j Address 6L Fs-2,q/ <br /> aOwner Address <br /> J Firm Partners, Addresses and Tele�ph/o Numbers <br /> a. Business Telephone No. `-�" ti �� Emergency Telephone No. <br /> j Contractor Licence No. <br /> � <br /> Applicants Name (Print) - Title �C�' 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 F <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. ❑ SANITATION PERMIT f <br /> Job Addr ss/Location (�1 <br /> O er Address ' <br /> EPTIC TAN CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> J5. CHEMICAL TOILETS For July 1, -June 30, 19 , <br /> _ Type Construction , _��w�_ Disposal Site — <br /> No.-of Uriits 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 /> A <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, an ules and r gulati f th Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X I <br /> _K1 d <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLAN ION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �S <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY t� <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. Is uance Date MailedDelivore <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE„P.O.Box 2009 STOC ON,CA 9 01 <br />