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Ik 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 SEP7AGE <br /> LIQUID WASTE, <br /> Applicatio h reby ma to c ry on b iness irlthe jurisdictional area of the San Joaquin L I H Ith is <br /> rBusiness NAme (DBA) Addre �S <br /> Address <br /> 4 Owner_I <br /> D S� <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CBusiness Telephone No. �ab �! Emergency Telephone No. <br /> Contractor Licence No. ✓�� f <br /> L Applicants Name (Print) Title Date 44 <br /> + -._1 <br /> Please check Applicable Category (1,-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE-PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For Jul1, �,June 3o,V 19 Disposal Sites j <br /> Descrip.t on,(Mal a/Yr., Color) <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PLUMPER YARD <br /> For July, 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored 4 <br /> 3. 11 PERCOLATION TEST rf <br /> R.S. or F .C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time t <br /> 4. `� SANITATION PERMIT ` <br /> Job Addres ocat'On ��13 <br /> Owner ' Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PITACKAGE PLANT <br /> �PERIMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER ♦ r <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 /> 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 /> !� I hereby Certify that I have prepared this application and that the work will be done in accordan a with San Joaquin County <br /> ordinances, state laws, a eAnd regula " Ijs of a San Joaquin Local Health Distri - <br /> (I <br /> APPLICANT'S SIGNATURE X <br /> } FOR DEPARTMENT USE NLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 'ZrPER SITE _❑ EACH ❑ January 1 c ived By January 31 ❑ July 1 &Received By July 31 <br /> � REMIT <br /> 'I BASE EXPLANATION BILLING REMITTAN E $ AMOUNT DUE CHECKED <br /> EI , DATE DATE REMITTED f�lJ AMOUNT <br /> FEE <br /> LESS <br /> PRORATEON <br /> PLUS <br /> PENALTY <br /> OTHER <br /> h <br /> hOTHEIR <br /> ii. . <br /> C] <br /> Permit No. Issu nce Date Mailed eliv red <br /> IlReceived 6y Date Receipt No 66 <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STO KTON,CA 95201 a "t <br /> 1 <br />