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Appli6411004 Will Be Processed When Submitted Properlycompleseo. taesure 1001yn IIIV <br /> _ APPLICATION <br /> (For Non-Translerable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> t Application I hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> I y Business Name(DBA) F1 �• 1`�s��-�I _ Address Zee �3 <br /> z Owner ��•�I Address <br /> 4 <br /> L Firm Partners, Addresses and Tlephone Numbers <br /> t aa. Business Telephone No. - �� Emergency Telephone No. <br /> Contractor Licence No. 41L_ _ <br /> Applicants Name (Print)_ �4: —Title ca.! ���� Date <br /> Please check Applicable Categgiy(1.7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLt 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 Star0d <br /> 3. ❑ PERCOLATION TEST <br /> RS'. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> ( 4. ❑ SANITATION PERMIT <br /> Job Address/Location �._.� � ' �' �'�� r� <br /> Owner _ 11�L_�/ -dv'��1J_�`r/1' "� Address °��� �^ <br /> Q�<EPTIC TANK 11 CESSPOOL R' ACHING FIELD P-'TEEPAGE PIT PACKAGE PLANT <br /> I ❑ OTHER'11PERMANENT ❑ TEMPORARY © NEW ❑ REPAIR <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 <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 /> l <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 law®, and rules and re ulatio s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ` <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT © PER SITE © EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> SE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE <br /> DATE DATE REMITTED AMOUNT <br /> FEE '( s— b _ <br /> LESS <br /> PRORATION <br /> FPLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance D to Mailed Deli -red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA�Z/ELTON AVE.,P.O.Bax 2009 STOCI(T ,CA 95201 <br />