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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application: <br /> 3YDri APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SFpTAGE _ <br /> t !/ ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is reby made tp carry on businessY businessthe juri dictional area of the n.Joaqui�n Local Health District <br /> Business Name (D ) Address <br /> z Owner <br /> f C` Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No. <br /> Business Telephone No. - <br /> Contractor Licence No. 2-7—` <br /> Applicants Name (Print,.).,,.. j Title Date <br /> Please check Applicable ategory(1-7) and Fill in the Require Information <br /> 1. .0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ' <br /> Fo July 1, June 30, 19 Disposal Sites "'tG <br /> R , <br /> I Description-(Make/Yr:,Color) rWV <br /> Serial No. CAL. License No. CAL.-License Renewal No. <br /> Capacity 4 t Gal.,Weights &Measures No. <br /> I <br /> Equipment Parkilig'Address <br /> 2. ❑ PUMPER YARD f <br /> It For July 1, - June 30, 19 <br /> No. of Vehicles Stored. <br /> j No. of Chemical Toilets Stored VIlk` . <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Date/Time <br /> Test Location <br /> 4. SANITATION PERMIT <br /> I. Job Address/LoW <br /> e- Address t _ <br /> Owner .. + �" s,. <br /> ❑ SEPTIC TANK CESSPOOL LEACHING,FIELDL`-1, S EPAGE PIT ❑ PACK GE PLy NT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 0[ " ,I REPAIR <br /> ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,_-June 30, 19 rJ <br /> Type Construction Disposal Site <br /> Equipment Stora Storage/Cleaning Location(s) r <br /> No. of Units9 g <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1,-June 30, 19 i <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <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 /> L� <br /> i 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 ions of the San 4gpquin Local Health District. <br /> APPLICANT'S SIGNATURE X sz-d</JGz <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT CI PER SITE. ❑ EACH ❑ Jan ary 1 & ceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING <br /> I - . .BILLING REMITTAN $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DA REMITTED AMOUNT <br /> G <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> �. .OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date <br /> ��� Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTO ..P.Yo�� $TOCKTO C 85201 <br />