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= Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 4 <br /> q (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT 51 PTAGE <br /> LIQUID WASTE <br /> Application i her by m to carryon usiness int e jurisdictional area of the S Joaqui ocaI Health District t <br /> t <br /> H Business Name (DBA) U Address U <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> E. Business Telephone No, Emergency Telephone No. <br />- �Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Informalion <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. I CAL. License No. CAL. License Renewal No. <br /> Capacity Gai.,!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.G.E. No. <br /> Test Location Test Date/Time ct <br /> 4. 1I SANITATION PERMi /so,�(0 0 't /,- a '7 ss <br /> Job Address/Locati n <br /> Owner Address - <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER rn <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 <br /> Operator Name Where Certified <br /> _ PlAnt Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19f <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft. — - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in"accor• qdance with San Joaquin County <br /> ordinances, state laws, and rules and g lations of an Jo uin Local Health District. <br /> -} <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTM 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 /> BASE EAPLANATION BILLING REMITTANCE $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE Ij Ap _ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 1 OTHER <br /> OTHER w <br /> e <br /> Received by Date Receipt No. Permit No. Issu nce Date Mailed Delivered x <br /> APPLICANT--RETURN ALL COPIES TO: :ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95261 � <br />