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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I <br /> APPLICATION �ooap-��p <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTt�I <br /> ENVIRONMENTAL HEALTH PERMIT 00 <br /> LIQUID WASTE y <br /> Application i ereby ma to carry business i the j risd'+ctional area of the San Joaquin Local Health Distri 7� <br /> rn Business Name BA) Address r-'22,4- 7G <br /> a Owner <br /> Address <br /> c0 Firm Partners, Addresses and Telephone Numbers <br /> a lf— 19_s-- Emergency Telephone No. <br /> a. Business Telephone No. <br /> Contractor Licence No. <br /> Title Date fQ ^3" <br /> L Applicants Name (Print) �f <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. Liccae 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 /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Dation Test Date/Time <br /> 4. ANITATION PERMIT 11-7 <br /> Job Address/Location <br /> O,wr �-nl�fi Address <br /> ;SEPTIC TANK ❑ CESSPOOL EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT �1 <br /> IMPERMANENT © TEMPORARY la NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 091 <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 /> I Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served i <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 /> t 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 gulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r <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 /> REMST <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> p PENALTY <br /> `lk OTHER <br /> ! 1 <br /> OTHER I <br /> [[ <br /> 99.. I/ <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed 'f <br /> _ pp REgURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT//}ERVICE$ 1601 E.HAZZELTON7AV_E.,P.O.Box 2009 .STOCKTON,C <br />