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sveApplications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEP�AGE <br /> L14u10 WASTE V � <br /> Application is i? y made t carry on business in the juris fictional area of the San Joaqu n Local Health DistrickD <br /> rBusiness Name D r �h <br /> y ( } Address— 7,6 7 <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. �fLsl G _ Emergency Telephone No. <br /> Contractor Licence No. L <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information 6` <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 r <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.C.E. No. <br /> Test Location Test Date/Time r <br /> 4. ❑ SANITATION PERMIT /` t <br /> Jab Address/Lo ation ! 1-1 t � RIF <br /> Owner Address I <br /> rt <br /> 1:1SEPTIC TANK 1:1C POOL 11LEACHING FEELD EPAGE PIT ElPACKAGE PLANT <br /> 1:1 PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 l W <br /> I <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'k <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.,Ft.L <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. _ <br /> y <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 a gulations oftheJo quin Local Health District. <br /> APPLICANT'S SIGNATURE X Y_ 4 <br /> L • r • <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH i ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE s S O <br /> LESS G t <br /> PRORATION 4A <br /> -11 <br /> PLUSPENALTY a6 <br /> OTHER v <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Vate I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HHAZEL�TONA,V�E.,P.O.Box <br /> 200009 STOCKTON,CA X9/52201 <br /> % <br /> s - R�LC�I/eseV 61 `6l.4,1RPA- 2,4) <br />