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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 Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT l` Go SEPTAGE <br /> LIQUID WASTE <br /> Appl is tion is hereby made to car on bustnes m the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) 7_2 � r �-_ 0 1, 1 '_ LjA,� <br /> Address _ <br /> z Owner -- — Address�3 ���. C��q <br /> J Firm Partners, Addresses a Telephone Numbers <br /> Q, Business Telephone No.3 Emergency Telephone N . <br /> Contractor Licence No. <br /> L Applicants Name (Print)� � jL.Z� Title Date S " <br /> ( Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O <br /> For July 1, June 30, 19 Disposal Sites <br /> r Description(Make/Yr., Color) <br /> Serial No. —CAL. License No: CAL. License Renewal No. <br /> --capacity", - Gal, Weights-&.Measures_No.~ <br /> I Equipment Parking Address <br /> 2. ❑ PUMPER YARD . <br /> For July 1, June 30, 19 <br /> 4 <br /> No. of Vehicles Stored <br /> T No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> 4 R.S. or R.G.E. Name + R.S. or R.C.E. No. <br /> Test Location - I t f FTest Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location nG- <br /> Owner ." Address <br /> ❑ SEPTIC TANK' ❑ CESSPOOLLEACHING.FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 13 TEMPORARY 13NEW F XREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 " <br /> Type_Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s)- <br /> --6. D.-PACKAGE TREATMENT PLANT For July 1, -June 30„ 19 <br /> Operator Name ”" " Where Certified <br /> Plant Location <br /> Plant Capacity r P'No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE? ❑ Less Than-1,000 Sq. Ft.,` _E3 More Than 1,000 Sq. Ft. i <br /> i <br /> ❑ DRY-CLEANING, Chemicals Used/Amount/Mo. � <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, staZ[aandrules"� d re ulationA of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUR 4' <br /> FOR DEPARTMENT USE ONLY <br /> Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT PER SITE 0 EACH ❑ "January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $, REMIT 1 <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE r <br /> LESS t� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER-,:,r,t., Q---•-:-_ ,---,-_ . .. -:�. __ -�_.-., a <br /> �`-79--7� 1 5 7 a4 <br /> Received by Date k Receipt No. Permit No. Issuance Date Mailed Deliv red r- <br /> 4�. <br /> APPLICANT—RETURN ALL COPIES TO: ,ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO KTON,C 952017 <br />