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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 SEPPAGE <br /> i✓ LIQUID WASTE <br /> Applica Ion is hereby made to r On buisine_.W in�the1'� ri dictional area of t_ a quin L c I Hea Istrlct -}— <br /> �I Busines Name (DBA) >� � {��. 1 �`I l��`F-� l Address � ` 0 <br /> z Owner LEE' NKI u B V Address � - <br /> Firm Partners, Addresses ph ne�N�umber <br /> IL <br /> Business Telephone No. �% Emergency Telephone No. <br /> Contractor Licence No. <br /> 4 Applicants Name (Print) Title ate C <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 N <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse 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. ❑ SANITATION PE IT <br /> Job Ad ess/Location t <br /> O ner Address45 4-50 _1 <br /> SEPTIC TANK ❑ CESSPOOL /&EW <br /> EACHING FIELD ❑ SEEPAGE PIT ❑ E;PACKAGPLANT ^ <br /> PERMANENT ❑ TEMPORARY REPAIR ❑'OTHER Cl <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. <br /> I hereby certify I have prepared this appiica ion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state law d rul sand egul tions the San Joaquin Local Health District. <br /> a <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 &4cived By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION fe DATE DATE REMITTE AM E CHECKED <br /> AMOUNT <br /> FEE <br /> LESS G �� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> OTHER <br /> Received by Date Receipt No. FrErmit No. Issliance Date Mailed rve d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON.AVE.,P.O.Box 2009 . <br /> ST <br /> TON,CA 5201 <br />