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Applicatio Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ` <br /> APPLICATION is <br /> (For Non-Transferable, Revocable, and Suspendable) ! -_ SZPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> L <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San.4a in Local ealt istrict <br /> OBusiness Na a (DPA) Address o[ CJ <br /> aOwner ! Address s° <br /> J Firm Partners, Addresses and Telephon Numbers f I� <br /> IL <br /> Business Telephone No. Q Emergency Tel <br /> Noll <br /> Contractor Licence No. <br /> Applicants Name (Print) Title I� Date r-- <br /> Please check Applicable Category (1-7) and Fill in the Required Information �I t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) •� J <br /> For July 1, June 30, 19 Disposal Sites II <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. I� <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD II <br /> For July 1, June 30, 19 li <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I! <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 j <br /> 4. R SANITATION PERMIT If <br /> Job Address/Loco ion <br /> Owner Address r <br /> a SEPTIC TANK ❑ CESSPOOL LEACHING FIELD Si SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY I&NEW ❑ .REPAIR rte : OTHER II <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site o� ,I <br /> No. of Units Equipment Storage/Cleaning Location(s) l� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �I <br /> Operator Name Where Certified <br /> R, <br /> Plant Location <br /> ii <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. y .I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i�. <br /> " - I <br /> I� <br /> li <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 regulations of the San Joaquin Local Health District. r <br /> i Z-- <br /> APPLICANT'S SIGNATURE X I' <br /> i <br /> E FOR DEPARTMENT USE ONLY <br /> f Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> IBILLING REMITTANCE $ i� RE <br /> MIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED i� AMOUNT <br /> -r <br /> L_ar 1d <br /> FEE <br /> LESS <br /> PRORATION <br />` PLUS <br /> PENALTY <br /> OTHER <br /> r OTHER II <br /> ii <br /> 1UlI S (O 0" bafit - <br /> Received by ale Receipt No Permit No. Issuance Date Mailed Delivered <br /> l APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON IAVE.,P.D.Boa 2609 STOCKTON,CA 95201 <br />