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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATIJN <br /> (For Non-Transferable, Revocable,and Suspendable) �, Iri . -.F <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applictition is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> to Business Name (DBA) Address/2. <br /> aOwner_. Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _3 O <br /> Applicants Name (Print) F-� i�1G,4. Title 019` Date Il-Z 1 <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 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.C.E. Name R.S. or H.C.E. No, <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location _ lvly a At ..� Tr"e".e <br /> Owner . bid X10 111tc a Address- <br /> SEPTIC <br /> ddress_SEPTIC TANK ❑ CESSPOOL X LEACHING FIELD �(SEEPAGE_PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY RINEW ❑ 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 r <br /> 7. ❑ LAUNDRY For July t, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. ( . <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> \l <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 regulati of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - " <br /> FOR DEPARTMENT USE ONLY I,-r-A f f <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jury 31/ J <br /> BILLING REMITTANCE 5 REMIT <br /> BASE EXPLANATION <br /> _ DATE GATE REMITTED <br /> AMOUNT DUE CHECKED <br /> a _ AMOUNT <br /> FEE — <br /> LESS <br /> PRORATION — - <br /> PLUS <br /> PENALTY l <br /> - f L c <br /> OTHER <br /> OTHER <br /> lam_ Q��Received by Date ReceiptNOPermit No. ce Date Majed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />