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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> APPLICATION 0�� 0,0 <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT S PTAGE <br /> LIQUID WASTE <br /> Application i r made o ar <br /> FB r�bu 'Hess in the jurisdictional area of the San Joaqui Loc Health Dis rictr <br /> y Business Nam {DBA = _ _. - <br /> i Owner ! Address . a _ / <br /> 4 " :Address <br /> Firm Partners, Addresses and T Ieph.QDe Numbe s ' <br /> CL Business-Telephone No, 19 <br /> Contractor Licence No. / Emergency Telephone No.. <br /> dc _ - <br /> L Applicants Name (Print) r n. _ G Title <br /> Please check Applicable Category(1-7)and Fill in the Required Information „� Y Date l <br /> I. El PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) # aYQ <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 t <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19' h <br /> -No. of Vehicles Stored <br /> No. of Chemical Toilets Stored er <br /> 3. ❑ PERCOLATION TEST a <br /> R.S. or R.C.E, Name r <br /> R.S. or R.C.E. No. <br /> Test ocation Test Date/Time ' <br /> 4. -SANITATION PERMIT / f 6 r d� G <br /> Job Address/Locate n ` <br /> Owner�,/�� E' Address ,Q v !- <br /> SEPTIC TANK OL ,0LEACHING FIELD SEEPAGE-PIT ❑ PACKAGE PLANT <br /> - <br /> ERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type ConstructionDisposalSite <br /> No. of Unitss' <br /> Equipment Storage/Cleaning Locations) F I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 • ' 3 <br /> Operator Name ¢, <br /> Plant Location 4 <br /> WherelCertified' <br /> Plant CapacityNo. 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. r t <br /> E <br /> I hereby certify that ! 'hav4rrep ' this lic Ion and that the work will lie done in-accordance with San Joaquin County' } <br /> :, .-.. ordinances, state laws, ande tip sof a Sari,Joaquin L al Health trict. - <br /> APPLICANT'S SIGNATURE X } <br /> 3 <br /> FOR DEPARTMENTUSEONLY <br /> Fee Is Due: ❑ ANNUALLY ❑_ PER UNIT. ❑ PER SITE ❑ EACH' ❑ January"1 &Received 8 .Januar 31 <br /> r - Y Y ❑__July 1 &Received By Juiy�31 <br /> BASE EXPLANATION 13ILLING REMITTANCEs $ REMIT } <br /> DATE DATE REMITTED AMOUNT DUE CHECKEDFEE - <br /> �. AMOUNT <br /> LESS { <br /> PRORATION <br /> PLUS / <br /> ' PENALTY - <br /> OTHER' $ <br /> OTHER. <br /> - .Received by I DateI r <br /> Receipt No: Permit No. ; Issuance Date Mail <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - - Delivered <br /> ' 1601 E.HAZELTO1N AVE.,P.O;Box 2009 STOCKTON,CA 95201 4 <br /> +r <br />