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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPl KATION g= <br /> (For Non-Transferable,re4ocable, and Suspendable) "- L. <br /> r 4 ENVIRONMENTAL. HEALTH PERMIT SEPTAGE <br /> f7 q U LIQUID WASTE <br /> Applicatttii�o��n't�is reby made to carry on business in the jurisdictional-area of th an Joaquin.Local Health District <br /> y Business Name (DBA)RA 1SFF � °"c Address r.D &k '14:750 �-rKAJ 9 SZQ7 <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print)�7 7�c �1�,�L��tL�iS Title0-� - 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. License 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 /> e 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Testi Location I.j( Test Date/Time <br /> 4. Er-SANITATION PERMIT--��,tl�� �j / ���.� Vx <br /> Job Addres /location ✓ <br /> O�.,wDer O Address ". <br /> L- SS TIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT 11 TEMPORARY 2-IIIEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction f 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 Y ry <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 T <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that Ih e prepared t •is applica an hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws rulesan r gulation the Joaqu 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 4 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE j <br /> LESS 4 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER # <br /> THER <br /> z <br /> Receivedby -4 Date Receipt No. Permit No. _ Issuance Dane Mailed. i '-Delivered <br /> ......... :e�":at,..... <br />