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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 SPTAGE <br /> LIQUID WASTE <br /> Applicationi ereby made t arty on siness in the jurisdictional area of the San Joaquin Local Health�DiIV Ct <br /> OF Business Name (DBA) r4� Address <br /> z Owner /1J81/ 0.0/e Address <br /> 9 <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. ' G Emergency Telephone No. <br /> X . <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information d <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites t <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL" License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> I <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 Location Test Date/Time <br /> l <br /> 4. 61�J-SANITATION PERMIT <br /> ��^ <br /> Job Address/Location f <br /> Owner -2-Y9 t9 ti*azoy, Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL GZ-LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY X NEW Al-REPAIR qTOTHER <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 i <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 /> d <br /> I hereby certify that I have prepared this p i a ion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and a nd r ul Ion of th San Jo uin Local Health District. <br /> r <br /> r <br /> APPLICANT'S SIGNATURE X <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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS G(y <br /> PRORATION CC <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER <br /> 62<9 'S <br /> Received by Date Receipt No. Permit No. Iss anc at Mailed Delivered <br /> - APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , <br />