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421 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 c`P A G 2 <br /> LIQUID WASTE <br /> Application is herebLy made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Address a Ict _� � 7`,e�j <br /> Owner_ Address- <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. _ �Ccad Emergency Telephone No. <br /> Contractor Licence No._ <br /> a Applicants Name (Print) Title 7-101 A'7aA'._ Date 9.`I�-.�� _ <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) - '*N1 <br /> Serial No. CAL. License No. —. CAL. License Renewal No. R�� <br /> Capacity . _. Gal., Weights & Measures No. u - <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 _ <br /> No. of Vehicles Stored <br /> No. of Chemicai Toilets Stored <br /> 3. ❑ PERCOLATION TEST — <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. Z <br /> Test Location —_ Test Date/Time <br /> 4. X SANITATION PERMIT G /y L A hie CAJ� G� <br /> Job Address/Location _._ in <br /> OwnerA?-�,�[ �k?`E��� G� _ Address •s ��, �,�/ d - / � n <br /> SEPTIC TANK ❑ CESSPOOL J�LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT ` <br /> PERMANENT ❑ TEMPORARY X 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. 1:1 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 /> rA- <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 regulations of the Sa aquin Locai 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 <br /> - _ _ By January 31 <br /> ❑ July 1 &Received By July$.1 <br /> BASE EXPLANATION BILLING_7 REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> EEE AMOUNT _ <br /> LESS <br /> .PRORATION <br /> PLUS <br /> PENALTY - — <br /> OTHER — r — <br /> OTHER ~ _— <br /> Received by_...__.._..-r-Date _ Rece- <br /> ipt No. Permit No. fssuance Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES a iv ed <br /> 1601 E.HAZELT0IV AVE.,P.O.Boa 2009 STO KTON, 95201 <br />