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Properly Completed. Be Sure To Sign TheApplication. <br /> Applications Will Be Processed When Submitted <br /> Y APPLICATION <br /> (For Non-Transferable;Redocable;and Suspendable) SP7AGE <br /> ENVIRONMENTAL HEALTH_PERMIT <br /> LIQUID WASTE <br /> Application is h de to car bu ss i e jurisdictional area of the San Joaqu�o 91 pis 'ct <br /> " y Business Name DBA) - ddress " <br /> aOwner Address _ <br /> Firm Partners, Addresses and Tel p one Numbe <br /> CIL <br /> Business Telephone No. Emergency Telephone No: <br /> 4 x. <br /> t _j Contractor Licence No. /.. <br /> Applicants Name (Print) Title-� �� _ . -„Date <br /> Please check Applicable Category.{1;7)_and Fill in the Required Information ;C ,�3t�. D6 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) _ <br /> Sites <br /> ” For July 1-,' June-30,19 �-- - Disposal <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 /> r For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored a' _ <br /> f 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R:S.or R.C.E. No. V r <br /> Test Date/Time <br /> Test Location t <br /> 4. SANITATION PERMIT <br /> Job Address/Location <br /> Owner i l Address _ <br /> t <br /> ❑ SEPTIC TANK ❑ CESSPOOL RLILEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ! <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEWS` REPAIR ,aOTHER f 0 <br /> 5. 11CHEMICAL TOILETS For July 1, -June 30,'19 t r <br /> �.. <br /> Type Construction -0 Disposal Site `- <br /> 1 ! <br /> No. of Units Equipment Storage/Cleaning Location(sy <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -dune 30, 19 r ;y <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 epar this appli ation and hat the work will be done in accordanbe with San Joaquin County <br /> ordinances, state laws, anul and`regulati sof the Joaquin.Local Health Distric . <br /> APPLICANT'S SIGNATURE X s - <br /> FOR DEPARTMENT USE ONLY;. <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT' ❑ PER SITE ❑ EACH ❑ January 1 &Received By! n 31 ❑ July 1.&Received By July 31 <br /> �. _. uary REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION + _ AMOUNT <br /> ,. DATEDATE 'REMITTED d� <br /> FEET..,-�.� jtP.- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER x ,w <br /> Received by - Date Receipt No. Permit No. issu nce Date ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERY[GES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br />