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A T Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applin. <br /> APPLICATION .,.n. <br /> . •-� <br /> - (For Non-Transferable, Revocable,and Suspendable) 5EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT f <br /> LIQUID WASTE <br /> - • Application is hereAy made to car on buss ess In the urisdictional area of the San J quin Local Health District /3 <br /> r S. _L.t�L. Address r� D� / .� �� I <br /> Business Name (DBA) �— <br /> z Owner Address <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. — Emergency Telephone No. <br /> Contractor Licence No. xadTJ9/2 Date �o-'z�-Iry 1- <br /> L Applicants Name(Print) 'T L S Title _j <br /> 1 <br /> Please check Applicable Category (1-7) and Fi11 in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> i <br /> Description(Make/Yr., Color) CAL. License Renewal No. t <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> '1 <br /> Equipment Parking Address ' <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 w3 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> - t R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test'Loc ion Test Date/Time <br /> 4. N SANITATION PERMIT <br /> O <br /> Jab Address/Location <br /> Addres <br /> O�wnSEl/1 �s,� <br /> L� PTIC TANK 1:1 CESSPOOL �-,/LEACHING FIELD L� SEEPAGE PIT ❑ PACKAGE PLANT <br /> 9 PERMANENT ❑ TEMPORARY 2 NEW ❑ REPAIR ❑ OTHER L/ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> j Plant Location <br /> r{ No. Units Served <br /> Plant Capacity <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. r <br /> I hereby certify that i h ve prepared this application and that the work will be done in accordance with 71 oa County <br /> ordinances, state laws, rules d regulns o he San Joaquin Local Health District. <br /> { APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> ❑ July 1 &Received By July 31 <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By anuar REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED' <br /> DATE DATE REMI E AMOUNT <br /> �y C <br /> i FEE <br /> 1 LESS <br /> l PRORATION y <br /> I PLUS <br /> t PENALTY <br /> ' OTHER <br /> OTHER <br /> • �r - I � h.. �V <br /> f3 Date Receipt No. Permit No ssuance ate Mailed Delivered `- <br /> Received by <br /> APPLICANT-RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA LT APF,.,P.O.Sox 2 STOCKTON,CA 95201 <br />