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Applications-Will.Be"ProeeSsed When.Submlited Properly Cgmpleted 9e Sure To Sign The Application. <br /> I <br /> APPLICATION <br /> _ -(For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> 4t; <br /> LIQUID WASTE I <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) :Address ' <br /> i Owner_ ,eUC15 <br /> Address 159 S �0 2U <br /> Firm Partners, Addresses and Telephone Numbers <br /> 4 Business Telephone No. Emergency Telephone No, <br /> Contractor Licence No. .. <br /> Applicants Name (Print) �NCrS �aT.� Title Date >�- 7 x <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> I. ❑ 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 Rer ival No. ' <br /> Capacity Gal„ Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 '. <br /> No. of Vehicles Stored ii �t <br /> Na. 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 _ <br /> Job Address/Location 9S <br /> Owner sa ii It Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 19 PERMANENT ❑ TEMPORARY NEW ❑ REPAIR 0 OTHER S uvr+,(JS <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 fI <br /> Type ConstructionDisposal Site <br /> No, of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT FOr'July 1, -June 30, 19 j <br /> i. <br /> Operator Name Where Certified - , <br /> Plant Location r <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 /> 1 <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 rules and regulations of the San Joaquin Local Health.District. <br /> APPLICANT'S SIGNATUREX � <br /> ' <br /> FOR DEPARTMENT 1 RTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER,UN17111. IOI PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 1 <br /> �,LANATJON, REMITBASE EXBILLING REMITTANCE $ AMOUNT DUE. : CHECKEDDATE DATE REWTTED .AMOUNT - <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 4 <br /> PENALTY 1 <br /> OTHER l s <br /> h <br /> OTHER <br /> 4L L6 <br /> Received by ate ..-". Receipt-No. - Permit No. — - 'Is uance D to-Aii�-- Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Box 20095 <br /> T0 <br /> C ON,-CA.95201. <br />