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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION I <br /> > (For Non-Transferable, Revocable,and Suspendable) + <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> „r, Business Name (DBA) Address � � <br /> I.- Owner �AddreLes Address --lye 5 <br /> a -� <br /> Firm Pad Telephone Numbers <br /> C6 <br /> Business Telephone No. 8� Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) �r� Title �� r Date . <br /> Please check Applicable Category�111nd Fill in the Required In rmation <br /> i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) b <br /> a <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. l <br /> 9 <br /> Equipment Parking Address <br /> 2. [3PUMPER 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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT a 6 <br /> Job Address/ ocation ! 5S r <br /> Owner f' Address kk <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> Q PERMANENT ❑ TEMPORARY © NEW ❑ REPAIR gOTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 l� <br /> Type Construction f Disposal Site N <br /> I j <br /> No. of Units Equipment Storage/Cleaning Location(s) 1 <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 0 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. a <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. Q—� <br /> f <br /> i <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, a d rulesA nd regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> BASE EXPLANATION _ BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS 1 <br /> PRORATION 1 <br /> PLUS <br /> PENALTY - <br /> OTHER .f <br /> OTHER <br /> Received by Date Receipt No_- Permit No. - Issuance Date Mailed Delivered 1 <br /> APPLICANT—RETURN ALL"COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON-AVE.,P.O.Box 2009 STOCK T N,CA 95 <br />