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~� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - APPLICATION <br /> (Por Non-Transferable, Revocable, and Suspendable) F <br /> ._;. <br /> ENVIRONMENTAL HEALTH PERMIT SEP -�E� ) <br /> " LIQUID WASTE I �� <br /> Application i hereb made to carry on b siness i the jurisdictional area of the San Joaquin Local He Ith istri + <br /> HBusiness Name (DBA) Address 6 4 <br /> i Owner Address <br /> 4 � <br /> Firm Partners, Addresses and Telephone Numbers T <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print)_-�rof d n i za Title Date <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 re Gal., Weights & Measures No. �.. <br /> Equipment Parking Address^ <br /> 2. ❑ PUMPER YARD ( <br /> For July 1, June 30, 19 1 <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.G.E. No. <br /> Test Location Test Date/Time f <br /> 4. P' SANITATION PERMIT r <br /> Job Addres Location 6 <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPO LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER [n <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> r <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) t } # <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 I <br /> Operator Name ) t Where Certified <br /> It <br /> Plant Location i <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. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.' <br /> � R t <br /> t <br /> r <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 and regulations of the San'Joaquin Local Health District. <br /> _ <br /> APPLICANT'S SIGNATURE X ,r � <br /> f 1 <br /> t <br /> rt ,yam FOR DEPARTMENT USE ONLY <br /> Pee Is Due: ❑ ANNUALLY PER UNIT !CA PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> -DATE DATE REMITTED' d AMOUNT <br /> FEE <br /> LESS - <br /> PRORATION l I <br /> PLUS - - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by DaReceipt No. Permit No. Issuan Dale Mailed Delive <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTALHEALTH PERMITISERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 STOC TON,CA5201 <br />