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Applications Will Be Processed When Submitted Properly CompleteBe u <br /> APPLICATION <br /> ' x17 :moi b <br /> (For Non-Translerable,Revocable, and Suspendable) SEPTACQE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LlQUiO WASTE � <br /> arry on busi s 'n the jurisdictiona area ofthe <br /> Application is hereb made <br /> San Joaquin Lnczl He�,Dil + <br /> to Business N e DBA) <br /> Address <br /> a Owner <br /> J Firm Partners, Addresses and el php�e umbers Emergency Telephone No. <br /> aBusiness Telephone No. v - <br /> Contractor Licence No. Title (late <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information y t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30. 19 Disposal.Sites 4 <br /> Description(Make/Yr.,Color) CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Gal., Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, <br /> June 30, 19 ' <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> TEST 3_ ❑ PERCOLATION T R.S. or R.C.E. No. <br /> R.S.or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> � 1 <br /> Job Address Loca on Addres <br /> Owner LEACHING FIELD SEEPAGE PIT ���T SEPTI ANK ❑ CESSPOOL REPAIR <br /> PERMANENT ❑ TEMPORARY NEW <br /> j 5. ❑ CHEMICAL TOILETS For July 1, -J e 30, 19 <br /> t Disposal Site <br /> Type Construction <br /> Equipment Storage/Gleaning Location(s) <br /> No. of Units <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> l Plant Capacity <br /> r - <br /> T. ❑ LAUNDRY For July 1, Jtine 30, 19 <br /> SIZE. ❑ Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. o <br /> ❑ DRY CLEANING, Chemicals Used/Amount/M0- ; <br /> ' <br /> he work will be done in accordance with San Joaquin County <br /> fiX <br /> I hereby certify that I have prepared this application and that t <br /> w <br /> ordinances, state laws, and rules and regulations San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X t. f <br /> t <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> T PER SITE EACH ❑ January 1 &Received By January 31 0 Juty'1 &ReceivedByJuly 31 <br /> PER UNI <br /> Fee IS Due: ❑ ANNUALLY ❑ $ AMOUNT DUE. CHECKED <br /> ' - BILLING MIT <br /> REMITTANCE' <br /> BASE ,.EXPLANATION DATE DATE t REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - - <br /> I. <br /> PLUS <br /> PENALTY <br /> j OTHER <br /> F OTHER ' <br /> 6�� �- <br /> - Mailed t7eliv <br /> Permit Nor issuance Date <br /> Dale Receipt No. - <br /> Received by � e4 1601 E.HAZEL70N AVE.,P.O.box 2009- STOCKTON,CA <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES <br />