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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 5EPTAGE <br /> LIQUID WASTE <br /> Application is her/made to carry% u ess in the jurisdictional area of the San Joaquin Local Health Di trlct <br /> mBusiness Name (DBA) `c' �" Address J�; <br /> aOwner I Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. �-� Emergency Telephone No. `�'f� +� c� <br /> Contractor Licence No. <br /> Applicants Name (Print) 'Z29 r �r,ca/r_�� Title Date i <br /> Please check Applicable Category (1-7) and Fill in the Required Information ;r ..r <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 /> 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. <br /> Test ocation Test Date/Time <br /> 4. 4 SANITATION PERMIT <br /> Job Address/L ation � C <br /> O ner Address <br /> SEPTIC ❑ CESSPOOL r.,1 LEACHING FIELD 0 SES- 1.� rT ❑ <br /> T K PACKAGE PLANT °~ <br /> PERMAN NT C] TEMPORARY L ;'NEWi?1 � ❑ REPAIRU ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -J/u0. 19. <br /> Type Construction_� �-t _ - ^' Disposal Site <br />--No. of Units "Equipment Storage/Cleaning Location(s)-- <br /> 65. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �D <br /> Operator Name Where Certified <br /> Plant Location <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 /> 5 <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,,arld rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE.. <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 /> SASE EXPLANATION AMOUNT DUE GHFCKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE C�s . <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER Q q <br /> Received by Date Receipt No Permit No ssuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2049 STOCKTON,CA 95201 <br /> OJ eoed -41 ttwjZa I 1`1­5�'31 <br />