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appiicat'ror►s WIII BeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> :a <br /> APPLICATION <br /> " (For Non-Transferable, Revocable, and Suspendable) P AA.4. <br /> t ENVIRONMENTAL ETH PERMIT <br /> Agt <br /> AP-Plication - ry`on b�ess int a jurisditi <br /> conal'area of the San Joaquin Local Hea <br /> H Business Name (DBA} isreby made to c !th District <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone N bAddress <br /> ers <br /> S r <br /> a Business Telephone No. ------------ <br /> �— <br /> Contractor Licence No. Emergency Telephone No. <br /> L Applicants Name (Print) N <br /> Please check Applicable Category Title r� KGs~ Date <br /> 9 ry(1-7) and Fill in the Req red Information � <br /> 1• ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For Jul I. I <br /> Y , June.3D, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. <br /> Capacity Gal.,-Wei hts.8�- CAL, Li;.ese Renewal No. <br /> 9 Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD Y4 <br /> For July 1, June 30, 19 .+ <br /> No. of Vehicles Stored _ <br /> .No. of Chemical Toilets Stored # I <br /> 3. ❑ PERCOLATION TEST f <br /> R.S. or R.C.E. Name <br /> Test Location R.S. or R.C.E. No. <br /> 4• ❑ SANITATION PERMIT / Test Date/Time l <br /> Job Address/Location /Owner /V ! � rC Lv e-.-,1 c /. D � . <br /> Address /F <br /> "❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT, ❑ PACKAGE PLANT <br /> ❑ PERMANENT' ❑ TEMPORARYNEW 5• ❑ REPAIR ❑ OTHER # <br /> 11CHEMICA'L TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site , <br /> No of Units Equipment Storage/Cleaning Location(s) . <br /> ti. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Plant Location Where Certified .f <br /> Plant Capacity <br /> 7• ElLAUNDRY For July 1, -June 30, 19� No. Units Served <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 applicatipn an`d that the wofk Will be done in accordanc4ith San Joaquin County f <br /> ordinances, state laws, and rules and of the Squi Local Health District. <br /> APPLICANT'S SIGNATURE X ; j <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITEt y <br /> ❑ EACH, .Q`January 1 &Received B anuar `$ <br /> t - . . y Jy 31 <br /> ❑ July 1 &-Received By July 31 <br /> BASE EXPLANATION BILLING C REMI.T-TANCE $ REMIT <br /> £ DATE DATE" '` REMITTED' AMOUNT DUE CHECKED <br /> FEE f F AMOUNT s <br /> 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> a OTHER <br /> OTHER <br /> _ Receipt No. PermrtiVo .. Issuance Date <br /> APPLICANT`RETURN ALL COPiE_5_TO: ENVIRONMENTAL HEALTH PEpMITfSEpViCES Mailed Delivered - <br /> 18p1 E.HAZELTON AVE.,P.O,Banc 2009 ;STOCKTON A 9520 . <br />