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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) <br /> SE PTAC-E <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on_t?,lsiness in the jurisdictional area of ftke San Jo qui.n-Local Health District <br /> Business Name (DBA) A��Isli�„' �} �Address 0 boo}-_4_�SO 4nt ! e. 01 <br /> z Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. -Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Applicants Name (Print) } $�j�� { Title ''f Date C Of <br /> Please check Applicable Category (1-7)and Fill In.the Required Information. <br /> 1.-,.0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Far July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> l Capacity Gal., Weights & Measures No.- <br /> Equipment <br /> o~Equipment Parking Address D <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 d <br /> 4. 'L-SANITATION PERMIT (� <br /> Job Address/Location ` <br /> O —I'sxto ,t:, Address <br /> ���SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT,. , ❑-.PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARY PN—EW ❑ REPAIR ❑,OTHER $ <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 .t e <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) 4� ' <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 y �.• d '"�,. ` <br /> r <br /> Operator Name Where Certified-2. <br /> Plant Location <br /> f <br /> Plant Capacity No. Units Served t <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/AmounVMo. <br /> � i <br /> t <br /> I hereby certify that I h e repared this ap lication and t e w <br /> the wor II b done in accordancith _ r�-Joagai oun y <br /> ordinances, state la s and_regul ons of the 5 aqui c Healt District_, <br /> APPLICANT'S SIGNATURE XIr� ` <br /> to y tIkt <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 /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ AMOUNT DUEA CHECKED <br /> P DATE DATE REMITTED AMOUNT <br /> FEE o <br /> LESS <br /> PRORATION <br /> PLUS 4 <br /> PENALTY <br /> OTHER <br /> e <br /> OTHER - <br /> Received by Date —' Receipt No Permit No. Issuance Date - Mailed •Delivered <br /> - <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />