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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAG <br /> LIQUID WASTE <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 /> zOwner s Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. � <br /> �Applicants Name (Print) vd Title Date <br /> Please check Applicable Category (1-7)and FIII 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 t, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored 0 <br /> 3. ❑ PERCOLATION TEST v <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 olOa7 ' e? X7p, <br /> ^ aVol7 ey/ �y <br /> Ow r Tif�rJ/�?+3S ES Address �J�,.2 �4.� y i� Gam✓. <br /> S PTIC TANK ❑ CESSPOOL ACHING FIELD ,-. SEEPAGE PIT ❑ PACKAGE PLANT <br /> L7 PERMANENT 11 TEMPORARY ;NEW <br /> ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site s <br /> No. of Units 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaq in County <br /> ordinances, state laws,mules and 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 B January 31 ❑ July 1 &Received By July 31 i <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> {L� AMOUNT <br /> FEE <br /> LESS l <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �a �a s� <br /> Received by D to i Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES 1601 E.HAZELTON AVE.,P.O.BOY 200 ST CKT (/J CA.liS201 <br /> ��t'7 <br />