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Applications W!I! Bes Processed When Submitted Properly Completed. Be Sure To Sign The Application. : <br /> _ �JS'/.'tet <br /> APPLICATION ���� <br /> _ (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT '" <br /> LIQUID WASTE <br /> Application is hereby mad to carry on b siness in the juris ictional area of the Sa Joaquin Local Health District <br /> Business Name DB _ Address (51 <br /> z Owner Address C' <br /> J Firm <br /> Partners, Addre Telephone qu <br /> mbers r f - F-� � f <br /> �7//,aBusiness Telephone Emergency Telephone . <br /> - <br /> 1 Contractor Licence No. c� <br /> Applicants Name (Print]_ �.��/c►.�. .T _. Title Date <br /> Please check Applicable Category(1-7)and Fill in.the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> t For July 1, June 30, 19 Disposal Sites \ <br /> [ Description(Make/Yr., Coior) <br /> w <br /> j Serial No. GAL. License No. CAL. License Renewal No. <br /> t Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address (( �� <br /> 2. ❑ PUMPER Y ID v1P <br /> For July 1t�ll: Nne 30, 19 <br /> I No. of Vehicles,Storedl,' <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 /> 1,Test Location'- Test Date/Time <br /> 4. A] SANITATION PERMIT- <br /> s/ <br /> ERMIT ,[ <br /> Job Address/L ation ..._� 7C ;424.7 S/ �'�`�� �V ��/ ,d 7Z/0'0p -" <br /> ; Owner`` Address <br /> SEPTIC TANK 11CESSPOOL -M<EACHING FIELD 11 SEEPAGE PIT PACKAGEPLANT <br /> PERMANENT ❑ TEMPORARY ❑.N'FLV ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June.30n19 <br /> Type,Construction _ � ' _�F'Sposal Site <br /> "- _ <br /> No. of Units. Equipment�torage/Cleaning Location(s) <br /> 6. ❑ PACKAG.ETREATMENT PLANT For July 1, -June 30,19 <br /> Operator Name J Where Certified <br /> Plant Location - <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY_-For July.1, v6e 30, 19 <br /> SIZE: ❑ Less Than 1;000 Sq. FL, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Cliemicais 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 /> r ordinances, state laws, and rules and regulations of the San Joaquin cal Healt Distri <br /> 40 <br /> c � <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> 111' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ` REMIT <br /> BILLING R TTANCE $ <br /> BASE EXPLANATION DATE XTEREMITTED - AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE r/ <br /> LESS <br /> PRORATION - <br /> F - PLUS i e <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> Received by D to Receipt No. Permit No Issuance Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMiTISERVICES•..m:.=R,_ 16011.HAZELTON AVE",P.O.Box 2009 STOC TON,C '45 01 _ .- <br />