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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ; <br /> APPLICATION y <br /> (For Non-Transferable, Revocable,and Suspendable) SpTAGE ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District r <br /> Address <br /> Business Name (DBA) -_ i aay . <br /> z Owner Address , <br /> a , k - <br /> Firm Partners, Addresses arid'Tele hone Numbers <br /> a Emergency Telephone No. ' <br /> CL Business Telephone No. <br /> a ' <br /> Contractor Licence No. Y11 i�ln`! t2 Date 7 <br /> LApplicants Name (Print) Title <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 C ` <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. Q 1 <br /> Equipment Parking Address - d` <br /> 2. ❑ PUMPER YARD�7, _ <br /> Y � <br /> For July 1, June 30,19 �r <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 /> �s <br /> 4. � <br /> SANITATION PERMIT , <br /> Job Addre lL;ation ` <br /> Owner t" Address <br /> POOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> r0 SEPTIC TANK PERMANENT 13 TEMPORARY ❑ NEW El REPAIR 13 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 a <br /> Where Certified <br /> O{3erator Name <br /> Plant Location '. <br /> -Plant CapacityNo. Units Served <br /> - t <br /> 7. ❑ LAUNDRY For July 1, -Jurie-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 <br /> t � r <br /> 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> F ordinances, state laws, and rule d regul tions of the San tluin Local Health District. ' <br /> APPLICANT'S SIGNATURE X <br /> r I , <br /> FOR DEPARTMENT USE ONLY <br /> a .1 &Received�.6y1 ❑ July 1 &Received By July 31 <br /> f Fee Is Due: ❑ ANNUALLY PER UNIT. ❑ PER SITE ❑ EACH ❑ Jams ry , <br /> ifl REMIT <br /> f BASE EXPLANATION BILLING REMITTANCE '- �$ AMOUNT DUE CHECKED <br /> RRRR DATE DATE _ 'REMITTED AMOUNT <br /> + .e-J / <br /> FEE S <br /> ' LESS <br /> PRORATION <br /> PLUS <br /> f PENALTY <br /> i` OTHER <br /> { OTHER <br /> f-20-7 �? ,4 0 0 1 <br /> - Received by Date Receipt No. Permit No. is uance Date - Mai ed Dehv ed .� <br /> - - - 1601 E.HAZELTON AVE. P.O.Box 2009_...--STO KT.ON,. .95201 <br /> '�- APPLICANT—RETURN ALL dOPIES TO: ENVIRONMENTAL-HEALTH PERMITISERVICES-'- `� /�'� �' �� �� <br />