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Applications Will Be Processed When Submitted Properly Completed, BeSureTo sign Ine,gppltcauon. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT 5E P7AGE <br /> LIQUID WASTE <br /> Applic hereby a to c on bus ss in the jurisdictional area of the San Joaquin Local H It D t <br /> w Business Na, a (DBA)!,a�"` a0 � � -Address `�' <br /> z Owner C Address <br /> a <br /> L) Firm Partners, Addresses and Telle ne_Nlumbe s <br /> aBusiness Telephone No. y � t Emergency Telephone No. <br /> Contractor Licence No. ' <br /> L Title Date r r- <br /> L Applicants Name (Print) — f <br /> Please check Applicable Category (1-7) and Fill in the Required Information p6 <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 <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 L cation Test Date/Time .� <br /> 4. SANITATION PERMIT <br /> Job Address/Location �7 <br /> Owner EL Address <br /> 11 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD E] SEEPAGE PIT El PACKAGE PLANT 1 <br /> PERMANENT TEMPORARY ❑ NEW 19REPAIR OTHER 74/1J) <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 5. 11 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 /> I hereby certify that I ares}this application and that the work will be done in accordance with San Joaquin Coulztdj <br /> ordinances, state law , an and regulatio f the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> C DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by pate Receipt No. Permit No. I s nee ate Mailed Dei red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Bax 2009 STOCKTON,CA 95201 <br />