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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 SEETAGE <br /> LIQUID WASTE <br /> Applicata n i her by�madeto r 9 usiness in t juri lcictiio`nal area of the an Joaquin Local H Ith District <br /> �;Busines ame (DBA) "�w�� Address-&.35 <br /> z Owner <br /> C Address <br /> a Firm Partners, Addresses a Tele honeumb S <br /> a Business Telephone No. — <br /> a / — Emergency Telephone No. — <br /> Contractor Licence No. <br /> L Applicants Name(Print), S Title Vfit'. - pate <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 /> r <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. 4 <br /> Tes�L,ocation Test Date/Time <br /> 4. SANITATION PEIIITV7� <br /> Job Addre s/Location ��''f� <br /> Owner �� � r or <br /> Addres <br /> SEPTIC TA K ❑ CESSPOOL LEACHING 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 July 1, -June 30, 19 <br /> Operator Name Where Certified- rni <br /> Plant Location Zj <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 /> t <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, an rules and regulati of an Joaquin Local Health District. <br /> TAPPLICANT'S SIGNATURE X <br /> - j <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 31 <br /> BILLING REMITTANCE $ - REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT I <br /> FEE A-45 c,&4--i&6 A15— <br /> LESS <br /> 1sLESS <br /> PRORATION <br /> e <br /> PLUS D <br /> PENALTY <br /> OTHER <br /> b <br /> OTHER <br /> 0 Lv 46 16-76S <br /> Received by pate I Receipt No. Permit No. Issuance Date Mailed elivered 6� <br /> !Z— I` <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIIYSERVICES 1641 E.HAZELTON AVE.,P.O-Box 20119 STOCKTON,CA 95201 <br /> r., y <br />