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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 /> ENVIR04MENTAL& LTH PERMIT Sf_PTAGE <br /> ff <br /> LIQUID WASTE 2—P3--Z2:6 <br /> Applications hereby made_to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Na {DBA) ~f 1f r r t` w+Y1,S Address j �f? r �� <br /> aOwner ik-4- _ Address _ 7 4, -5-`_ <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. `µ 7f Emergency Telephone No. <br /> � Contractor Licence No. <br /> Applicants Name (Print} ' r G'�' r^r E a->` Titled �rt� Date r �" <br /> Please check Applicable Category(1-7) and Fill in the Required Information. `tel <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30, 19 Disposalites <br /> Description(Make/Yr., Color) I <br /> Serial No. CAL. License NO- CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. { <br /> Equipment Parking Address JI <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored [J+ <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST Co <br /> X <br /> R.S. or R.C.E. Name R.S. or .C.E. { <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/1 ocation j r <br /> 'All/C C F- 4 5"� <br /> Owner Address -C' , <br /> -SEPTIC TANK ❑ CESSPOOL MLEACHING FIELD ❑ SEEPAGE IT ❑ GE PLANT <br /> El PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ ER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Const tion Disposal Site <br /> No. of Unitnc _ _ _ __ 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 Serve <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 0,M ore Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that 1 have prepared,this application and that the work will be done ii I accordance with San Joaquin County <br /> ordinances, state laws, and rules an�..r�- tions of the S Joa uin Local Healt Distriat. Q� ' <br /> APPLICANT'S SIGNATURE X - <br /> f <br /> i <br /> FOR DEPARTMENTUSE NLY <br /> Fee Is Due: [].ANNUAL-LY--,.❑._PER-UNIT—❑„PER,SI,T,E, E]rEACH ❑_January 1 &Received By January 31 ❑ July 1 &Received By July.3T�i <br /> - r, T x REMIT <br /> BILLING REMITTANCE - $.�' ,�,,.. -- <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE "GHECKED; <br /> AMOUNT <br /> FEE 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER, p <br /> �b� L4 I �[ (o <br /> Received by D to Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,GA 95201 <br />