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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. \ <br /> APPLICATION <br /> (For Non-Translerable, Revocable, and Suspendable) . <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl ication 's her by m e to carry o usi ss the jurisdictional area of the 5 Joa u' Local He Ith District <br /> y Business (DBA) Addre ��� �- &D5W <br /> a Owner _ AddressRP <br /> — <br /> Firm Partners, Addresses and Telephone Numbers �a <br /> aBusiness Telephone No. 3� Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print) Title AM's- Date <br /> Please check Applicable Category (1-7)and Fill In the Required Inlormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) _ <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) w <br /> Serial No. CAL. License N%, CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. r <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 '.' A--� <br /> R.S. or R.C.E. Name '!. R.S.or R.C.E. No. <br /> TestLocation Vest Date/Time <br /> 4. B SANITATION PERMIT i _Ieo <br /> Job Addres ocation <br /> Owner AddrA, <br /> ❑ SEPTIC TANK ❑ CESSP0CV ❑ LEACHING FIELD R SEEPAGE�Pd ❑ PACKAGE PLANT i <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW U101§EPAIR ❑ OTHER i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 i <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 /> hereby certify that I have prep his applica n and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r regulation S n Joaquin Local Health District. <br /> r i <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT _ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS _ <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Deliv/g ed <br /> APPLICANT—RETURN ALL COPIES TO: EN�TM��L HEA,LTHpERM1T� 1�E����o>t 200��OtZKTO) 95201 �r <br />