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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> 4 (For Non-Transferable, Revocable,and Suspendable) CQ <br /> �. SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE V� <br /> Application is ereby made to carry on business in the jurisO3ctional area of the SaDJoaqyjn Local Health District <br /> yBusiness Name(DBAddress <br /> i Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. � 1 d Emergency Telephone No. <br /> Contractor Licence No. ';n z- <br /> G <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) <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 /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L ation Test Date/Time - <br /> 4. I SANITATION PERMIT <br /> Job Address/Lo ation <br /> Owner ( G�4-c a Address Q ��`�' J'y 3 �r r-..F - � Z 2 7 <br /> ❑ PTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> l!� PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR M'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) <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 /> 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, and rules_and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ZCPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING MITTANCE $ <br /> BASE EXPLANATION DATE/ DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE % r ��/J (// <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER P <br /> �1 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed 4DeeliveedAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boxx20 9 CA 201 <br /> fit�/C N <br />