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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) <br /> u I� ENVIRONMENTAL HEALTH PERMIT $FpTAGE <br /> LIQUID WASTE <br /> Application is hereby made to car ort business in the jurisdictional area of the San Joaquin Local He�altthj,Is#rict <br /> l y Business N me(DBA) IMS_ Addre s SE ` `'A <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No, Emergency Telephone No. .. <br /> Contractor Licence No. <br /> I L Applicants Name (Print) - f Title � Date,3.'— <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> k 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 € y� u <br /> Job Address/Location ' ewf o� <br /> r Owner Addr <br /> SEPTiC TANK ❑ CESSPOOL LEACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT <br /> 1 ❑ PERMANENT ❑ TEMPORARY ❑ NEW R IR ❑ OTHER <br /> k <br /> S. ❑ 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 1 <br /> Plant Location <br /> I: 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 /> t�l pS- <br /> I hereby certify that I have prepared this application and that the work will be done In acc rda ce with San Joaqui��unt <br /> ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. •� IT� <br /> .APPLICANT'S SIGNATURE X � L '«✓'1/4 �111�� P aM - <br /> z <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED. AMOUNT DUE CHECKED <br /> I 'uI AMOUNT y,(� <br /> FEE <br /> E LESS <br /> PRORATION f <br /> PLUS <br /> PENALTY 4 <br /> OTHER <br /> OTHERn r <br /> Received by Vate Receipt No Permit No. Issuance Date Mailed Delivered <br /> k APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />