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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication <br /> I APPLICATION <br /> *f"= (For Non-Transferable, Revocable, and Suspendable) <br /> SE PTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicat,on is her made Vicar on usin s in the jurisd'ctional area of the �Joa uin Local Health Di tric !amu <br /> 1. N LiI <br /> Business Name (DBA Address <br /> z Owner Address <br /> a <br /> i J Firm Partners, Addresses and Telephone Numbers <br /> a &Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> ti. Title Date <br /> LApplicants Name (Print) pd <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) A <br /> I For July 1, June 30, 19 t" Disposal Sites. <br /> Description(Make/Yr., Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> p 2. ❑ PUMPER YARD <br /> f For July 1, June 30, 19 <br /> No. of Vehicles Stored r <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Na. <br /> R.S. or R.C.E. Name Y <br /> Test Locate n Test Date/Time <br /> R 4. ANITATION PERMIT <br /> Job Address/Location <br /> Owner Addre��SEEPAG�EPIT �1133 <br /> [1SEPTIC TANK ElCESSPOOL LEACHING FIELD ACKAGE PLANT <br /> O- <br /> 2'PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �, s <br /> Type Construction Disposal Site <br /> t No. of Units Equipment;Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT'For July III'-June 30, 19 -- <br /> Operator Name Where Certified <br /> .r <br /> Plant Location <br /> ( ' No. Units Served <br /> Plant Capacity <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: El Less Than 1,000 Sq. Ft-, 13-More Than-1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo.'. <br /> I hereby certify that l haAprepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, slate laws, n les and ulatio the Sa aqui Local Health District. <br /> APPLICANT'S SIGNATURE X a <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &ReceivendEBy1 July 31 <br /> BASE EXPLANATION DATE <br /> REMI TANCE $ AMOUNT DUE CHECKED <br /> PATE TE REMITTED AMOUNT <br /> FEE <br /> Sf �5` <br /> LESS <br /> PRORATION ! - <br /> �/ Imo`-ami - <br /> PLUS Q `( IQQ <br /> PENALTY <br /> OTHER W <br /> Received by Date Receipt No Permit No. Is uance Date Mailed - Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 -STOCKTON,CA 952x1 <br />