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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIR " ll" TAL HEALTH PERMIT SEATAGE <br /> LIQUID WASTE <br /> Application is hereb made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA) R• S,el SumS Address C 1 <br /> i <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. b6 Emergency Telephone No. <br /> Contractor Licence No. eZb <br /> Applicants Name (Print) N0.v1112_ w t Ork _ Title Date a <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. Liccnze Renewal No. <br /> Capacity Gal.,Weights &Measures No. W <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 Location Test Date/Time <br /> 4. A SANITATION PERMIT _ <br /> Job Address/Location �• ��► QO <br /> Owner.<s.>61.KX'� Z7• 5 fh= 5'S7Z0S Address <br /> ❑ SEPTIC TANK 1:1CESSPOOL ❑ LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 54 REPAIR ❑ OTHER -" <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 /> 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 /> 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, an s and regulations of the San 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT 14 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS s <br /> PENALTY o <br /> OTHER <br /> OTHER <br /> — f 7 <br /> Received by - Date Receipt No'.— Permit No. T Issuance Date Mailed Deliv <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STD KTON,C 9S <br />