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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 SEPTAGE <br /> LIQUID WASTE <br /> Application,r�1y m�de,to car on busine n the'urisdicti nal area of the San Joaquin Local He th istrlc <br /> H Business Name (DBAI)—Ira C� cV ick Address C 5 <br /> aOwner—M 1 6vel- Address d-tz S, <br /> Firm Partners, Addresses and Tel h e Numbers <br /> a. Business Telephone No. wx" Emergency Telephone No. <br /> Contractor Licence No. 1 <br /> Applicants Name (Print) �� Title �S/� 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. Lic::nse Renewal 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 <br /> No. 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. ArSANITATION PERMIT <br /> Job Address/Location <br /> Owner 4y AN��wi <br /> e Address <br /> 11 SEPTIC TANK 11CES POOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT OTEMPORARY `XNEW REPAIR ❑ 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) —T <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 /> r <br /> I hereby certify that I ha ared this application and that he work will be done in accordance with San Joaquin County <br /> ordinances, state law an and Tegulations of e,,San J quin 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 By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS J <br /> PRORATION <br /> PLUS <br /> PENALTY T <br /> OTHER <br /> OTHER <br /> i <br /> Received by Date Receipt No. Permit go. issuarke Date Mailed Del iv ed f <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCI(TON,CA95201 <br />