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1 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 <br /> LIQUID WASTE <br /> Applicatio Is her y ma tic ry on bu ess i t <br /> r �ejurisdictional area of the Sa oaqui - cal Health pis i <br /> N Business Nam� BA) ` ��Jr <br /> y ,� dress. _ <br /> a Owner "-�. `` Address <br /> Firm Partners, Addresses andTel Pphone Numbers <br /> aBusiness Telephone No - ' � -i ? Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) of --G/� �S <br /> —� Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l/ <br /> For July 1, June 30, 19 <br /> - _ Disposal Sites <br /> Description (Make/Yr., Color)- <br /> Serial No. CAL. License No. <br /> 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 tion Test Date/Time <br /> � <br /> 4. i�SANITATION PERMIT — — <br /> Job AddLassftocationAdc <br /> 4 - ��� <br /> Owner ��� 7 v C + S <br /> 0SEPTIC TANK ❑ CESSPOOL &-LEACHING FIELD res�/SEEPAAGGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 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. t <br /> Horne owner orlicer—r1a.�e,. c�igrtai�rreoertl'r3 t.,• e <br /> in such maltor's Wr to becv a wh ect tr l3 rk, s tr h sten Y.-e t cert;4 r s the aer`._rrr�nc�1)f the Yrork f or vlaich this permit is issued,I r hall not em to an <br /> Contractor's Farina Cr s sS a rt P y y Per:;" <br /> employ persons siisiect to r� ,3,, " ` sty ctkrwrng: 'i rrt,;r,i,al,;�¢tie;� rt r;rar, e ul the work for which this per;rlit Is issued,I shall <br /> ., ur„„.us ..L,�4.r� ,.u. <br /> I hereby certify that I have prepared this appy ation a that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, s and Of th an Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ <br /> i- —. January18,gecelv8,Aeceivea By January 31 El July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING T REMITTANCE REMIT <br /> — — — _ DATE — DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> EEE <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY — ,� - '• <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permlt No <br /> d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES i suanc Date MaileDelivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 20(09 STOCKTON,CA 95201 <br />