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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I APPLICATION <br /> I (For Non-Transferable, Revocable,and Suspendable) ©��~ <br /> SI_PTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 2I�E'�_S IG&LIQUI[1 WASTE <br /> Application iebv rt)adeto�arry on bus ess the'uris fictional area of the Joa in Local Health Di t <br /> �n Business Na (DBA) Address��� T �� ��- � <br /> aOwner -'LG Address `%e ,'� - <br /> Firm Partners, Addresses and Tele hone Nu ers <br /> J y <br /> 0. Business Telephone No. '�� D Emergency Telephone No. <br /> Contractor Licence No. Z7--6- <br /> Applicants <br /> Applicants Name (Print) Title Date YI7 <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> i 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) F <br /> Serial No. CAL. License No. CAL. Liccnse Rencw4 No. <br /> Ii Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD _ • <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> f. 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. s <br /> Test Location Test Date/Time Q, <br /> 4. ❑ SANITATION PERMIT t ' ^. <br /> k Job Addres /Location r:,1.)� �T 1 �'`���h� 4�1d� <br /> Owner Address ®'S r en <br /> ❑ SEPTIC TANKI ❑ CESSPOOL LEACHING FIELD ❑ SPAGE PIT PACKAGE PLANT <br /> 13PERMANENT ❑ TEMPORARY 11L'NEW REPAIR ❑ OTHER <br /> a 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ; <br /> Type Construction Disposal Site <br />} <br /> No. of Units Equipment Storage/Cleaning Location,(s) t <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 ;. <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 /> { <br /> I here by certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Y Y p P y <br /> ordinances, state laws, and rul nd regulations Sa Joaquin Local Health District. 1 <br /> APPLICANT'S SIGNATURE X per[} <br /> I 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 /> I REMIT <br /> t BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE �( AT REMITTED [� AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Pe mit No, Iss ance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON_AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />