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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 5EPT ,CE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Nazge ( BA) Address <br /> zOwner / Address ,_ <br /> Firm Partners, Addresses and Telephone-Numbers <br /> a Business Telephone No. � �� Emergency Telephone No. —_��_- __ , <br /> a <br /> Contractor Licence No. - <br /> LApplicants Name (Print) � '� 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 too. <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.C.E. Name R.S.or R.C.E. No. <br /> Testi Dation - Test Date/Time <br /> 4. G SANITATION PERMIT f <br /> Job Addresslk'gcati n 7,31—/ <br /> Owner�lC�, f / � Address_ <br /> ASEPTIC TANK ❑ CESSPOOL'PRI�,�L^EACHING FIELD OR SEEPAGE PIT ❑ PACKAGE PLANT <br /> 13ERMANENT TEMPORARY In NEW ❑ REPAIR ❑ OTHER <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 /> 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 p p red this applic and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r1d re lation the San Joa n Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> = �. ., <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE y <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date I Receipt No. Permit No. ISI / <br /> ate Mailed DeIiv red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO KTON, A 95201 <br />