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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) t <br /> ENVIRONMENTAL HEALTH PERMIT ' SEPT G <br /> LIQUID WASTE <br /> I Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District _ <br /> I. Business Name (DBA)_ o% � �"�' ilh . Address d �^ <br /> z Owner 1� (r.� CSC Address <br /> Firm Partners, Addresses and Telepho a Numbers <br /> Business Telephone No. L e!6 Emergency Telephone No. <br /> Contractor Licence No. d'� <br /> } , Applicants Name (Print) ,r Title 1_S-17 Date <br /> kI 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.License Renewal No. <br /> Capacity Gal.,Weights & Measures No, <br /> Equipment Parking Address <br /> j 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> r No. of Chemical Toilets Stored <br /> µ 3. ❑ PERCOLATION TEST k <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> FTest Location Test Date/Time <br /> 9___1 4. SANITATION PERMIT _ 5 �o�./�✓ / <br /> Job Address/Location `� � fi . . _ <br /> Owner <br /> e/r'' Address a )ejo <br /> E SEPTIC TANK ❑ CESSPOOL LEACHING FIELD P SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> 177I Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <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 /> H ' <br /> z 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, aid r[aTeSS)and regulations of the 5an 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 $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> h PLUS <br /> PENALTY <br /> OTHER <br /> it OTHER _ _g <br /> F tl '' } - .. -. y.x "� y�1F"":�1- ,yr,.iw 3� i .4•,Y., �� '- '{+'- _ � _ c t .4r"sa�'„r.K��� <br /> .•[s.Y} ' 6tc -,.? �. .,'� F'�1•"�,4 w - �, 3 gyri�§`` - r^ -� - <br /> , .- ,.�...x'gt�„asK -�.a.w6 - �' .. A`+' '.+,s ,,"` _$ YYsisR! .Sa``x�rs" -' „+h'•- {Cai . ,x°'�'-+'''? L'c. x "R +'r,�a+, .i ' <br />