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Applications Will Be Processed When Submitted Properly Completed. Be Sure Tn Sign The Applicaiion. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,'and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SIPTAGE <br /> LIQUID WASTE <br /> Applicatio �]ereby de to carry on wyness the juris cti nal rea of the San J uin al Ith District <br /> y Business me (DSA) r Z �_.��Q(1]��vdress <br /> aOwner -. Address <br /> ,Firm Partners, Addresses and lephone Numb rs <br /> a Business Telephone No. <br /> a / Emergency Telephone No. <br /> Contractor Licence Nv. <br /> Applicants Name (Print) ��� Title , Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> r 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> I 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 /> k 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 /> 4. ❑ SANITATION PERMIT t rJ <br /> Job Address/Location 'R& f!'; <br /> Owner Address r I <br /> ❑ SEPTIC TANK . ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR 5�-6THER <br /> 5. 13 CHEMICAL TOILETS For July 1, -June 30, 19 e_5_ 4)ed �/ y <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., ❑iMore Than 1,000 Sq. Ft, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> s <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, and rules and reg 'ons, the S oaquin Local Health District. <br /> t <br /> APPLICANT'S SIGNATURE X <br /> t <br /> � FO EPARTXO <br /> NL <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH ❑ Januar 1 &Received B Januar 31 <br /> Y Y Y ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE - EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> f <br /> } - AMOUNT <br /> FEE } } f- <br /> LESS `� <br /> PRORATION y <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ' !� 47a� <br /> -S 11xi �_6 <br /> Received'b ,• Date Receipt No Permit No. - I suanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,CA 95201 <br /> L — . j <br />