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f Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i ere�by mad to carry on business in the risdictional area of the Sa Joaq/ui�Local Health District <br /> NBusiness Name (D ) 4 Address �• � <br /> aOwner n Address ? <br /> Firm Partners, Addresses and Telephone Numbers ' <br /> aBusiness Telephone No. '�/C s Emergency Telephone No. <br /> -j Contractor Licence No. <br /> 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) l€ <br /> For July 1, June 30, 19 Disposal Sites I <br /> Description(Make/Yr., Color) <br /> Serial No. <br /> CAL. License No. CAL. Licznse Renewal No. <br />' _ �I <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address �J <br /> 2. ❑ PUMPER YARD 4 �( <br /> For July 1,. June 30, 19 ! <br /> No. of Vehicles Stored 00 <br /> II ) <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 /> TeseSANITATION <br /> on Test Date/Time <br /> a <br /> 4. PERMIT <br /> Job Address cation 2- <br /> Ow <br /> i <br /> Ow r - Addres�s...,� <br /> 0I PTIC TANK. ❑ CESSPOOL 2'LEACHiNG FIELD lig-SEEPAGE PIT ❑ PACKAGE PLANT <br /> L� PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> li <br />: ;i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br />' Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Serveld <br />' 7. ❑ LAUNDRY For July 1, -June 30, 19 g <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq, Ft. <br /> I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> l <br /> I hereby certify that I have prepared this application and that the worJvvill be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules ^egulationsof the.San)oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X i - <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNITC3/PFR SITE ❑ EACH ❑ 'Lnuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i BILLING REMITTANCE $ REMIT , <br /> FI BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE L�. <br /> S� <br /> r LESS l� <br /> 4 PRORATION I' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r- <br /> OTHER Ij <br /> 4 Received by Date Receipt No. //!/Pemitfo. ii lErsuance Dae Mailed elivere <br /> APPLICANT—RETURN"ALL cOPIES TO: - ENVIRONMENT Ii lHl ICES J .1601 E.HAZELTON AVE.,P.O.Box.2009 CA 95 1 <br />