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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 SEPT ,C E- <br /> ' LIQUID WASTE <br /> Applicatio �erepymado arty o usines in th juri I tional area of the S oaq Local Health DistrictwBusiness Name BA) Addressy 7� <br /> z Owner Address <br /> C <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No.$��� �¢ Emergency Telephone No. <br /> Contractor Licence No. Z <br /> L Applicants Name (Print) Title Date s r <br /> Please check Applicable Category (1-7)and Fill in the Require nformation <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 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 Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R. E. Name R.S. or R.C.E. No. <br /> Test ation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job ress/L ation Q �4 '�°"` <br /> Owner Address d <br /> ❑ SEPTIC NK ❑ CESSPOOL LEACHING FIELD PAGE PIT ❑ PACKAGE PLANT <br /> 10:1PERMANENT E] TEMPORARY 11NEW M'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 r, <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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and gulations of the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jaar 1 July &Received By July 31 <br /> 71 REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REM TTE AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I uance Date I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />