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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) SI PTAGE <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 <br /> N Business (DBA) Addre <br /> eOwner Address <br /> J Firm Partners, Addressesan Tele hone Numbers <br /> aBusiness Telephone No. 0-su i Emergency Telephone No - , <br /> Contractor Licence No. - - ; <br /> Applicants Name {Print) Title ,nU3PAt�- Date a4 <br /> Please check Applicable Category (1-7)-and Fill in.the Required Information_ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) V� <br /> For July 1, June 30, 19 "DisposalsSites r - <br /> Description(Make/Yr., Color) C(\Serial No. ti CAL. License CAL. License Renewal No. . <br /> Capacity ' Gall Weights-&--Measures No%_.: ^ '�^'�"""'- <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 ,/� <br /> No. of Vehicles Stored ,•' 1 J• `' e <br /> No. of Chemical Toilets Stored 1 _ <br /> 3. ❑ PERCOLATION TEST rt t <br /> R.S. or R.C.E. Name Y 4 R.S. or C.E. No. , <br /> Test Lo ion Test{ atelTrme. ? & •r tt <br /> d <br /> 4. l SANITATION PE IT <br /> Job Ad /Location ' 1' <br /> { <br /> Owner � � Address <br /> %-SFPTIC TANK 0 CESSPOOL � -E' ACHING Fitt-D ❑ SEEPAGE PIT <br /> M'PERMANENT TEMPORARYW ❑ REMR-'' ❑ OTHER <br /> 11 .q>,� a �• t <br /> 5. CHEMJCALJOILETS,,F_-br',July 1, -Ju�o, 19 _il <br /> }y✓� 4 d .; <br /> Type Construction �-- Disposal Sid <br /> x i <br /> No. otlUngSs Equipment Storage/Cleaning Location(s) i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 s- y <br /> Operator Name r ` Where Certified <br /> Plant Location <br /> Plant Capacity ! ---�N6"Un_its SerV d <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 /> 1 <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 and regulations of the San Joaquin Local Health District..;, 4 _ <br /> APPLICANT'S Szl <br /> IG ATURE X { --1. y <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REM4TTED - AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> F PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER a / <br /> OTHER - <br /> t <br /> Received by A Datle Receipt No. er it.No. Issuance Date- Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />