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Applications Will Be Processed When Submitted Properly Completed. Be Sere To SI�c n The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> t ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE. <br /> Applicatloq is herb ade to car n b . ss i' a jurisdictional area of.the San Jo quin oc I Heglth District <br /> Business Name ( BA) Address L <br /> aOwner dress !►fg D ,Q(< t <br /> ,Firm Partners, Addresses and Telephone umbers <br /> CL a Business Telephone No. �- Emergency Telephone No. <br /> a Contractor Licence No, <br /> L Applicants Name (Print) Title 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 R Measures No. <br /> Equipment Parking Address.. <br /> 2. ❑ PUMPER YARD O, <br /> For July 1, June 30, 19 M <br /> No. of Vehicles Stored r{. <br /> No. of Chemical Toilets Stored . c <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. �Q SANITATION PERMIT G <br /> Job Address/Location Ile ;.. / / ( C ,,- <br /> Owner <br /> Address <br /> '❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT El PACKAGE PLANT <br /> 13 PERMANENT' ❑ TEMPORARY, , NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July"), -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 /> Operator Name <br /> _ Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY; For.July 1, -June 30, 19 <br /> SIZE; ❑ Less Than"I,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,-Chemicals Used/Amount/Mo. <br /> 4 <br /> I-hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules an regulations of.the Sa oaquin o I He Ith istrict. <br /> APPLiCANT'S SIGNATURE), <br /> FOR DEPARTMENT USE ONLY <br /> Feels Due: 13ANNUALLY. © PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Recewed By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT CHECKED <br /> DUE ` <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS r /� <br /> v '7 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I� <br /> OTHER - <br /> C) l a <br /> Received by aieReceipt No. Permit o. Essuance Da a Mailed eliv ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ - 1601 E.HAZELTON AVE.,P.O.Sox 2oD9 $TO TON,CA 95 J.-1� �' <br />