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Applicatiollib WIII Be Processed When Submitted ProperlyCompleted. BeSureTo SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> T UQ�UID WASTE <br /> Application is.hereby made to carry on business in the jurisdictional area of the n Joa uin Local Health District t <br /> ,n Business Name (DBA) , —� � Address 6 __�� —CAIN <br /> a Owner ^ - <br /> Address r <br /> U Firm Partners, Addresses and Te e h rte Numbers <br /> a . <br /> Business Telephone No. � Emergency Telephone No .�f <br /> Contractor Licence No. �At <br /> Applicants Name (Print) �7 ■ u��' '- Title 6 w'rI/zy� Date "� d <br /> Please check Applicable Category(1-1) Odd 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. r— <br /> Capacity Gal.,Weights & Measures No. i <br /> Equipment Parking Address <br /> I <br /> 2. ❑ PUMPER YARD <br /> For July 1,_-June 30, 19 No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> - r <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name __.____ R.S. or R.C.E. No. <br /> i <br /> Test Location _ Test Date/Time ffF <br /> 4. ❑ SANITATION PERMIT e ! <br /> Job Address/Location ( <br /> I <br /> Own — .�A — b .L CU �� Addres,-s�-,,,�� <br /> SEPTIC TANK 1:1 CESSPOOL LEACHING FIELD ter- EPAGE PIT ❑ PACKAGE PLANT ' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ 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) j <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -.lune 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/Amdllnt/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules an egulattons of the San Joaquin Local Health District. � <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy l &Received By July 31 <br /> t <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i - DATE DATE REMITTED AMOUNT <br /> FEE ! v 1 <br /> LESS / <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER ] <br /> L _7 <br /> Received by Dale - Receipt No. Permit IN0. Issuande Date Mailed_ Delivered , <br /> APPLICANT.—RETURN ALLCOPIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT� / <br /> O�N AVE.,A.O.Box 2009 STOCKY N,CA"5201 ^' <br /> i �f�i 7--j //5' I <br />