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Applications Will Be Processed When Submitted Properly completed. Be Sure To Sign The Application. l�r <br /> r APPLICATION <br /> -io <br /> k ' (For Non-Transferable evocable,and Suspendable) <br /> " ENVIRONMENTAL HEALTH PERMIT SEP7AGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Iy Business N me (DBA) Address <br /> z Owner <br /> a Address 1 C <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. <br /> Emergency Telephone No. <br /> Contractor Licence No. G rri3 46(. — �0 7 tea <br /> L Applicants Name (Print).4e rLGjtie Date <br /> `C <br /> Please check Applicable Category (1-7)and Fill In the Required Iniormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites c� <br /> Description(Make/Yr., Color) <br /> { Serial No. CAL. License No. CAL. License Renewal No. <br /> I 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 /> x Test Location Test Date/Time <br /> F 4. WSANITATION PERMIT <br /> Job Address/Locationyj <br /> -S 4 1 a906 /V <br /> OwnerP- 41,Vd/fe. Address • <br /> SEPTIC TANK ❑ CESSPOOL gr LEACHING FIELD ❑ PACKAGE PLANT 07 <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER iA <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 (i'J <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 x <br /> Operator Name Where Certified <br /> i 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 - <br /> t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin. qu n County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S NATURE X <br /> FOR DEPARTMENT USE ONLY } <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT [].PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITZRE <br /> REMIT <br /> BASE EXPLANATION -AMOUNT DUE CHECKED . <br /> DATE DA <br /> AMOUNT F <br /> FEE LESSPRORATION1PLUS <br /> PENALTY ✓f W ' <br /> OTHER <br /> F <br /> OTHER <br /> /�7 -305zo-LC) 81 t s B-6 <br /> Received by; Date Receipt No. Permit No. I uance ate Mailed �-Delivered - <br /> 9 <br /> - APPLICANT tR 13iN ALL GOPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2000 STOCKTON,'-�n <br />