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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 30 - § <br /> (For Non-Transferable, Revocable, and Suspendable) � <br /> ENVIRONMENTAL HEALTH PERMIT SPTAGE <br /> LIQUID WASTE C <br /> x Applicatio 's hereby m et carryo onus e n the jurisdictional area of the Joaq Local Health D' trict, Uj <br /> Business me (DBA Address ` ! <br /> te <br /> z Owner i Address 06 , " <br /> a <br /> Firm Partners, Addresses and Telephone Numbers 0vtIt- �S <br /> aBusiness Telephone No. �.3 6,P'503-3 Emergency Telephone No. � I <br /> Contractor Licence No. <br /> L Applicants Name (Print) c cls kWf Title — 64oA)eRDate b <br /> Please check Applicable Category (1-7) and 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. <br /> Capacity Gal., Weights & Measures No. <br /> '`Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 l <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S.or R.C.E. No. ri <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location & � ! <br /> Owner Address N <br /> ®EPTIC TANK ❑ CESSPO&. C'-LEACHING FIELD B—�EEPAGE PIT ❑ PACKAGE PLANT W <br /> Ci-PrERMANENT El TEMPORARY Cg—NEW ]'REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Tr <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> k 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br />'i Operator Name Where Certified C; <br /> Plant Location 7 <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 y <br />' SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.1t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> I hereby certify that I have prepay d this applic ,on and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r d reg ulatio h San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 44 <br /> FOR DEPARTMENT USE NLY� <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ ar J,.ICReceived By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> M T <br /> k BASE BILLING RE $EXPLANATION AMOUNT DUE CHECKED <br /> DATE D REMITTED <br /> AMOUNT i <br /> FEES <br /> LESS <br /> PRORATION - A_ <br /> PLUS , <br /> PENALTY <br /> OTHER <br /> OTHER i <br /> r ! f a� <br /> Received by - Date Receipt No, =Permit No. Issuance Date- Mailed RN ALPERMIT/SERVICES E. Derivere <br /> - <br /> APPLICANT—RETURN COPIES TO: ENVIRONMENTAL HEALTH P �A/ 1601 HA EL AVE.,AP.O.Box 2009 STOCK ON,CA 95 1 <br /> � ,..,�. �V -moi ��j�"�VE.,---- .- <br />