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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 l�1 <br /> �IQulo wnsTf: <br /> Applicati s herebyrr de to carryon bt�iness in the jurisdictional area of the San Joaquin Local Health District �. <br /> H Business Name DBA - - <br /> ( ) `. Address z,' j! � <br /> zOwner <br /> a A - CSC;-'f:!Y Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �� 1� Emergency Telephone No. <br /> Contractor Licence No. r^ J '1 <br /> L Applicants Name (Print) Title '2 _ Date Z12 J7 <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 R.C.E.No. _ <br /> Test Location Test Date/Time <br /> 4. V SANITATION PERMIT <br /> Job Addre Location– � Jy N 1 ,X4 <br /> Owner ___ 7-4�1 _ ._ Address ✓d/� _.__/i' � .�- —_.. __ <br /> SEPTIC TANK ❑ CESSPOOL PrLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT TEMPORARY ❑ 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 Juiy 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, 1 <br /> SIZE: ❑ Less Than 1,D00 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;a rules and regulations of 1pe San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE <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 3t <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE HEMITTED AMOUNT <br /> z <br /> FEES <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _ I <br /> 79�_ �� <br /> Received by Date Receipt No, Permit No -Issuance Date Mailed ID.. <br /> APPLICANT—RETURN ALL COPIES To! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCK ON,CA 201 <br />