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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION '� h <br /> "1 (For Non-Transferable, Revocable,and Suspendable) <br /> } ENVIRONMENTAL HEALTH PERMIT SEETAGE <br /> t LIQUID WASTE <br /> Appl icaf is reby de tzarry b e I e tlrisdictional area of the San Joaquin tical He It Distric <br /> OBusiness Name (DB A) Address �� r 1 <br /> z Owner Address S OSD. <br /> a _ <br /> J.Firm Partners, Addresses and e <br /> pj,on N mb rs ( ,t <br /> aBusiness Telephone No. __ S1 Emergency Telephone No. `rlJ <br /> Contractor Licence No. 3� ( ////_��_ <br /> LAppficants Name (Print). ` l Title Z3Tf Date <br /> PleaseichecW.Appl cable 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 IY <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> I <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address I 1 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 rT� <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 1 <br /> I <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> p <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT �5 <br /> JotAddress/Location ! � I �O� Z�2, <br /> Ownele �45 Im Address 13 & RCIAFOIN <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAG 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 ! <br /> Plan! Location t <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 6;qleFt:' <br /> ,. <br /> ❑ DRY CLEANING, Chemicais Used/Amount/Mo: �•� <br /> it _ <br /> I hereby certify that I hav repared this application and that the�work"will sbe done-in accordance with San Joaquin County f <br /> ordinances, state law a d lei and r/e'.gulions of a San'Joaquin L"ocalHeafuhDistrict. ' <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONL'Y----- . <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT P4 P_ER SITE ❑ EACH ❑ lanuary,l_8 Rece_i_ved B_y January 31 ,,, ❑ July 1 &Received By July 31 <br /> REMIT <br /> ir <br /> BASE EXPLANATION BILLING y REMITTANCE $ AMOUNT DUE CHECKED `I <br /> ,.� DATE DATE . REMITTFD AMOUNT <br /> i !f <br /> FEE f:� L}7 !_g <br /> LESS j Alm} <br /> PRORATION <br /> PLUS <br /> PENALTY r s <br /> OTHER <br /> OTHER -79 <br /> [ -� �! <br /> Received by Date l Receipt No Permit Na Issua ce Date Mailed Deliv red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,1'4201 <br /> II -. �, , -r -- , <br />