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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SE PTAGE <br /> LIQUID WASTE <br /> Applicatio Is he e y ade to car on la Hess in t jurisdictional area of the San Joaquin Loc Health District ' <br /> rn Business Name (DBA) `�1��S Address <br /> z Owner Tf'"t �j��G r�� Address 6 � <br /> J Firm Partners, Addresses andlephone Numbers I <br /> aBusiness Telephone No. Y Emergency Telephone No. <br /> Contractor Licence No, y 3 <br /> L Applicants Name (Print) �1 �"� riR+i Title Date <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. 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.O.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ER SANITATION PERMITl��C�1 � � �T <br /> Job Addre� Location <br /> Owner +� 0,i LeN'0-74'V Address ���✓�' � ' <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 f <br /> Type Construction 4DO 9011 lle!_1 /_ 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, and ules and regulations of the Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X R <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 15L PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE ys <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY C <br /> OTHER <br /> OTHER <br /> Received by Date I Receipt No, Permit No Issuance Date Maited ve <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STO TO 95201 <br />