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v Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheAppticanon. 4 <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA)— "� Address Z -t� ���� <br /> z Owner Address <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> Date <br /> LApplicants Name (Print), 1 <br /> 1 }fin}3 Title _ <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I <br /> For July 1, June 30, 19 Disposal Sites I <br /> Description(Make/Yr., Color) <br /> Serial <br /> CAL. License No. CAL, License Renewal Na. <br /> N <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. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT Tl <br /> Job Address/Location S 4. s <br /> Owner act& 4F:7XAddress <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> t <br /> 13PERMANENT ❑ TEMPORARY C1NEW } REPAIR C3 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 e <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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> { Plant Capacity No. Units Served <br /> r <br /> I 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 accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the S aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> ❑ ❑ ❑ ❑ EACH ❑ January 1 &Received By January 31 El July 1 &ReceivedREMITuIy 31 <br /> Fee Is Due: ANNUALLY PER UNIT PER SITE <br /> REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION BILLING <br /> DATE DATE REMITTED AMOUNT <br /> � FEE <br /> LESS <br /> ` PRORATION .0 C <br /> k PLUS U <br /> PENALTY� y G r�SL L I � 1� war <br /> OTHER � <br /> rank wry+ � <br /> OTHER (f <br /> IF15 ance ate Mailed Delivered <br /> Received by Date Receipt No. ermit o- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95207 <br />