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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> l APPLICATION <br /> ! (For Non-Transferable, Revocable, and Suspendable) $EpTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl ication ' hereby made to carry on siness in the jurisOctional area of the San Joaqul Local Health District <br /> Business Name ( BA) Address 24 7= <br /> I a Owner Address - -- <br /> J Firm Partners, Addresses and Telephone Nu ers <br /> CL <br /> Business Telephone No. �g /{�— Emergency Telephone No. <br /> l <br /> Contractor Licence No. <br /> Applicants Name (Print} Title Date <br /> Please check Applicable Category (1-7)and Fill in t e Requi d Information Q <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> t 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 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> a 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E.No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location ` � <br /> O,wrl r l Address IMH alg=eL FX 4.1e_ <br /> ASEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD �T ❑ PACKAGE PLANT � <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER 0 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -`_June 30, 19 <br /> Type Construction 1 Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,119 <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., © More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> j <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 rut nd regulationss of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> { <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE - EXPLANATION DAMOUNT DUE, CHECKED <br /> ATE DATE REMITTED <br /> I I _ ( f AMOUNT <br /> FEE c { L `� �f <br /> + <br /> PRO _ <br /> �I <br /> PRORATION (((///vvvv"'�����- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> f Received by -Date Receipt No.-- P rmit No. - l uance ate - Mailed Delivered ' <br /> t' - APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P,O.Box 2009 - STOCKTON, A 201. <br />