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Applications Will Be Proces16d When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _ APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT F SEPTAGE <br /> LIQUID WASTE <br /> Applicati .is hereby made car on bu 'Hess i the juri ictio al area of the S o ui ocal Health D" trict ,c <br /> rn Business Name (DBA). 2 S ;0_ b Address B <br /> aOwner E S Address <br /> L) Firm Partners, Addresses and Tele hone Numbers ' <br /> aBusiness Telephone No. � � W Emergency Telephone No. <br /> Contractor Licence No. �7O <br /> L Applicants Name (Print) P Title h e! Date 'y <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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Locationd' !-� ;/4�6!/s �/ ��7 JQor.�,7 __ <br /> Own Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ® OTHERe� <br /> 5. 11CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction I Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) _ <br /> S. ❑ PACKAGE TREATMENT PLANT ForiJuly 1, -June 30, 19 ) <br /> Operator Name "L Where Certified <br /> Plant Location14. <br /> I� <br /> Plant Capacity No. Units Served �n <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. t <br /> o <br /> /V/V „ <br /> I hereby certify that I.have prepared this application and that the work will be done in accordance with San Joa C unty , a <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. y�I�l G `� A <br /> G• I ! <br /> APPLICANT'S SIGNATURE X <br /> 1 FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. .❑ PER SITE ❑ EACH ❑ January 1"&Received By 4nuary 31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> BILLING REMITTANCEfr <br /> BASE EXPLANATION DATE DATE R TED AMOUNT DUE CHECKED - <br /> i C,[ AMOUNT <br /> FEE _ 011 <br /> I � a` <br /> LESS - f f <br /> PRORATION r <br /> i <br /> PLUS <br /> PENALTY <br /> OTHERi k rly <br /> OTHER <br /> "Received by I Date I Rec,6ilYt Nd. Permit No, I suance a e Mailed elivered 'fir <br /> APPLICANT— ? <br /> _ RETURN ALL.COPIESO: ENVIRONMENTAL HEALTH PERMITfSERViCES 1601 E.HAZELTON AVE.,P.O.Box 2909 ' STOCKT ,CA 195201 <br />