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Applications Will Be Processed When Submitted Properly Completed. be bure iu <br /> ! <br /> APPLICATION <br /> r j (For Non-Transferable, Revocable,and Suspendable) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the Joaquin Leal Health Distri <br /> c%lJ P S� V c_ Address�]� [JJ d <br /> N Business Name (DBA) p �j �u3T� h <br /> aOwner C T' Address I <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. � <br /> aBusiness Telephone No. <br /> 1 Contractor Licence No. %3 <br /> Title z Date <br /> a <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7) a4 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 /> CAL. License No. CAL. License Renewal No. <br /> Serial 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 R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name \ <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT a <br /> JobAddre s/Location <br /> Address /d / <br /> Owner 'r ❑ PACKAGE PLANT <br /> 13 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD F-1 SEEPAGE PIT <br /> 11 PERMANENT <br /> ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> l <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location Q <br /> No. Units Served <br /> Plant Capacity <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 /> County <br /> I hereby certify that I h prepared this application and that the work will be done in accordance with San Joaquin Ca y <br /> I ordinances, skate laws, nd rules and r/ ulatio f the, an Joaquin Local Health District. <br /> I APPLICANT'S SIGNATURE X <br /> /, <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: [3 ANNUALLY ❑ Pr UNIT0 PER SITE ❑ EACH © January 1 &Received By January 31 C] July 1 &ReceW.d Byl July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> # <br /> FEE 4 <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> i OTHER <br /> OTHER <br /> � Permit No � �Issu nee Date Mailed Delivered <br /> Received by Date Receipt No, <br /> APPLICANT-RETURN ALL COPIES T O •ENVIRONMENTAL HEALTH PERMIT/SERYICES 16D1 E.HAZELTON AVE:,P.O.Box 2009 STOCKTON,CA 85201 <br />