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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> y APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is he y made to rryo business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) �� x1 r4 we Address ! CD, <br /> aOwner_'U&/'� _ �� iuC Address <br /> J.Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> f Applicants Name (Print) ek41/ Title �'� Date <br /> 3 Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. 13 PUMPER VEHICLE PERMIT REGIS'T'RATION (FOR EACH VEHICLE) ( �� <br /> For July 1, June 30, 19 11 Disposal Sites 1J) <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. a <br /> 1 Capacity Gal.,,Weights & Measures No.. <br /> Equipment Parking Address <br /> 2, ❑ PUMPER YARD <br /> i <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored , <br /> i No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name A.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location y��y� ��_- �/� p` O <br /> Owner Z> .t <br /> Address <br /> �JErSEPTiC TANK ❑ CESSPOOL ?❑ LEACHING FIELD Cl SEEPAGE PIT ❑ PACKAGE PLANT <br /> +PERMANENT ❑ TEMPORARY NEW ❑ REPAIR AiLOTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ; <br /> Type Construction Disposal Site <br /> No. of Units Eq{filament Storage/Cleaning Location(s) <br /> _ 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> ( Where Certified i <br /> Plant Location y <br /> Plant Capacity i 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 /> }, <br /> 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 ` and gul 29 of th an Jouin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> .K F <br /> { FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNLIT ❑ PER SITE ❑ EACH ❑ January 1 &Received-By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION NCE $ AMOUNT DUE CHECKED <br /> _ I DATE DATE REMITTED AMOUNT <br /> FEE L+ <br /> LESS <br /> PRORATIONy- <br /> PLUS <br /> PENALTY <br /> OTHER t <br /> OTHER t L f �" <br /> Received by Date Receipt No. Permit No Issuan a ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL AVE.,P.O.Box 2009- TOS C�ICTON,CA 95201 <br />