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d Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i [ APPLICATION . <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> I LIQUID WASTE <br /> F <br /> Application 's hereby made to car y on business in the jurisdictional area of the San oaqui Lo al Health District <br /> Business me (DBA) Address �C <br /> i z Owner - Address <br /> a Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ---?'� �+ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) 4 Title t _ Date <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f + <br />( For July 1, June 30, 19 Disposal Sites 1! <br /> Description(Make/Yr., Color) <br /> E Serial No. CAL. License No. CAL. Llccrlse 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 /> ff No. of Chemical Toilets Stored <br /> h 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 /> E 4. &SANITATION PERMIT �h JJob Address/ cation r f �ec. <br /> Owner Z L& Address !�f <br /> 0 SEPTIC TANK ❑ CESSPOOL Nr LEACHING•FIELD ❑ SEEPAGE PIT. - ❑ PACKAGE PLANT <br /> - ''E�PERMANENT ❑ TEMPORARY ❑"NEW' ""'"'"'" 1 .REPAIR— ---0"OTHER <br /> " S. :❑ CHEMICAL TOILETS For July 1, -June 30, 19 " d <br /> _Type Construction_ - = Disposal Site - <br /> :No`of Unitswquipmeht Storage/Cleaning Location(s) { <br /> az <br /> `6. ❑ PACKAGE TREATMENT PLANT For!July 1, -June 30, 19 <br /> Operator Name I -_ -�• --- - Where Certified <br /> s� <br /> Plant Location • a j <br /> Plant Capacity No. Units Served ` <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ` 4. <br /> SIZE: ❑ Less'Than 1.000 Sq. Ft.` C1.More Than 1,000 Sq. Ft. <br /> '❑ DRY CLEANING, Chemicals Usecl4mounV_Mo <br /> x K~ <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, state laws, anj rules and regulations Okthe an 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 By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE f�j�t REMIT <br /> BASE EXPL NA ION DATE DAT PEM TTED AMOUNT DUE CHECKED <br /> �{ [ <br /> II/ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION 1 <br /> PLUS �} <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by ate J Receipt No. Petmir No. ISS ance ate - Mailed sliver d- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,.P.O:Box 2009. STOC To <br /> C 95 1 <br />