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Applications Ill Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> SEP7AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ' LIQUID WASTE <br /> Application i hereby mad t carry on busin ss in he j isdictIonal area of the�an Joaquin Local Health 'sEric�� ^��6 5 <br /> r Business Name (D ) - Address v- <br /> s Owner <br /> '° Address <br /> uFirm Partners, Addresses and Telephone Numbers i <br /> Q. Business Telephone No. — fd Emergency Telephone No. <br /> Contractor Licence No. <br /> a L Applicants Name (Print) Title f. ; <br /> Please check Applicable Category x(1-7)and Fill in�theReq�,Illlnfolmltion <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 �.�+ Disposal Sites <br /> t Description(Make/Yr.,-Color) — CAL. License Renewal No. <br /> Serial No. �f CAL. License No.LL� N <br /> Capacity Gal., Weights &'Measures No. "4 <br /> Equipment Parking Address W� � _tom <br /> 2. ❑ PUMPER,YARD 1 <br /> i` For July 1, ,June 30, 19 <br /> YY No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R . or R.C.E. No. <br /> R.S. or R.C.E!Name <br /> r <br /> Test L titian .II Test Date/Time <br /> I 4. SANITATION PERMIT <br /> Job Address/Location <br /> . w Address <br /> O er <br /> ❑ PACKAG <br /> �E <br /> PLANT <br /> -TANK ESSPd'OL LEACHING FIELD SEEPAGE PIT <br /> SEPTICO❑ REPAIR THER <br /> ❑ PERMANENT TEMPO <br /> _ \V_ <br /> / <br /> 5. .13 CHEMICAL TOILETS' Ford July 1-June 30, 19 / <br /> 1111 4 't�- Disposal Site <br /> Type Construction <br /> No. of Units IM Equipment Storage/Cleaning Location(s) i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,`June 30, 19 C <br /> Where Certified <br /> Operator Name A <br /> i <br /> I Plant Location -- <br /> i. <br /> Plant Capacity No. Units Served <br /> r _�_ <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> P. <br /> SIZE: ❑ Less Than 1,000 Sq'!�Ft.,v' ❑ More Than 1;000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> �y <br /> herebycertify that l;have prepared this application and that the work will be done in accordance with San Joaquin County <br /> t ordinances, state lawsl and rules and ulations of the S Joaquin Local Health District. <br /> l APPLICANT'S SIGNAT^IJRE X _ <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY I�, ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January49[off1 & 8y January 31 ❑ July 1 S Received EB'ytTuky 31 <br /> i IM BILLING REMITT 'NCE 4 AMOUNT DUE CHECKED <br /> a BASE EXPLANATION ED AMOUNT <br /> r DATE DA E REMITT <br /> Iwi <br /> FEE t c� <br /> LESS A yI <br /> PRORATION { I!r <br /> PLUS lI <br /> PENALTY III <br /> OTHER <br /> E <br /> OTHER — <br /> II, <br /> F eDate Receipt No. Permit No, Issuance Date Maile Delivered <br /> Rceived by <br /> 1601 E.HAZELTON AVE.;P.O:BOY 2009. bTOCKTON,GA 95207 <br /> I APPLICANT—RETURN ALL CO'PIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES <br /> IIII <br />