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Applications Will Be Processed When Submitted Properly Completed. $e Sure To Sign TheApplication. <br /> APPLICATION ���, <br /> 10r, <br /> (For Non-Transferable, Revocable,and Suspendable) SEPfA- '`'' E VI NTAL ALT PER IT <br /> 5 S� � E � 7 = <br /> n is er b add'to carry on business in the jurisdictional area of the Sa501Joquin Health District <br /> Application Y <br /> Address <br /> anBusiness <br /> Business Name (DBA <br /> C Address <br /> aOwner ­ <br /> J Firm Partners, Addresses and Telephone Numbers , Emergency Telephone No. <br /> a Business Telephone No. <br /> C 0, 011 <br /> Contractor Licence No. <br /> Title ) <br /> L Applicants Name (Print) <br /> "�"� Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information r " <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) W <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> I Gal , Weights &Measures No. <br /> Gal., <br /> Equipment Parking Address , <br /> 2. ❑ PUMPER YARD i <br /> For July 1, June 30, 19 ; <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored =mss <br /> 3. C1 PERCOLATION TEST '`�` QJLc e-t G� y <br /> r R.S. or R.C.E. Name �—� v:'• 3 <br /> i4 Test Location Test Date/Time <br />` 4. ❑ SANITATION PER y� <br /> Job Address/Location <br /> S ,--�� Address [] PACKAGE PLRNT <br /> Y LEACHING FI�Lb„ .Q�SEEPAGE PIT <br /> SEPTIC TANK ❑ CESSPOOL; , ,. . t ❑ OTHER <br /> ❑ PERMANENT ❑'TEMPO0AAY-t... =.,,NEW4 -REPAIR y <br /> _ " r <br /> 5. ❑ CHEMICAL TOILETS For July i, -Jun-e-30, 19 <br /> Disposal-SiteF ` <br /> Type Construction - A F,� ` <br /> No. of Units y' Equipment storageYCleaning-Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For'July 1, -Juner30, 19 B Where Certified <br /> Operator Name n ` <br /> -Plant Location <br /> Plant Capacity­ No. Units Served <br /> M - <br /> 7. El LAUNDRY For July 1, -June 3019---- + <br /> Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 5q. Ft., ❑ More r � <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. } v. <br /> 4 <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 regu 'o W f the San Joaquin Local Health District. ^ <br /> k N( <br /> APPLICANT'S SIGNATURE �� <br /> L f C <br /> ' � P <br /> ( FOR DEPARTMENT USE ONLY <br /> ❑ PER UNIT ❑ PER SITE ❑ EACH 13 January 1 &Received By January 31 E3 July 1 &Receiv REMITBy uiy 31 <br /> Fee IS Due: ❑ ANNUALLY <br /> f -aw + BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION �, DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS r - <br /> PRORATION <br /> PLUS17 <br /> " <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a Receipt No. Permit No, 1 anc ate Mailed Delivered <br /> Received by Date <br /> 1601 E. AZELTON-AYE.,P.O.Bax 21109 � STOCKTON,CA 95201 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES <br />