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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 _.,j;EPT-.AGE <br /> LIQUID WASTE t <br /> Applicatio hy to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) 4' �7 4—c'-l-, 54500CaO Address f 7Q,5- -T, <br /> eOwner I. Address L <br /> Firm Partners, Addresses and T pho a Numbers <br /> a. Business Telephone No. _ 'q19 oZ6o/(o Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name(Print) 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 /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) + <br /> Serial No. CAL. License No. CAL. License Renewal No, <br /> Capacity Gal., Weights & Measures No, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD s <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> i <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST fi <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 9 SANITATION PERMIT 'We- <br /> - <br /> r <br /> Job Addr Locatio / OQ r /(l/V $l - S'�G�i' •�i C- <br /> Ownernsov Address—/ <br /> SEPTIC T NK 11CESSPOOL LEACHING FIELD At SEEPAGE PIT ❑ PACKAGE PLANT <br /> 0 <br /> PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 4 <br /> w <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 R`ry <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 1 <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 County4 <br /> ordinances, state laws, a es and regula ' ns of the an Joaquin ocal Health District. '� <br /> r <br /> APPLICANTSIG <br /> Ex <br /> - I <br /> FO DEPARTMENT USE ONLY <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑'FACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> . .BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> 4 <br /> FEE <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by DateReceipt No. Permit No Jsbuande Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601=E.HAZELTON AVE.,.P.O.Box,2009 STOCKTON,CA 95201 - <br />