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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) `F f!'1_F_ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati i r y e ry n s j nal area of the San Joaquin Local Health District <br /> Zr.� e� <br /> r Business ame (DBA) r ? Add <br /> a Owner 11�� Y � l�/�L� /1 ress <br /> J Firm Partners, Addresses a d Tel ho Numlaers <br /> aBusiness Telephone No. r J Emergency Telephone No. <br /> Contractor Licence No. G <br /> a Applicants Name (Print) C5.F Title Date 6 � <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 <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. Na�m-e�� t,l'NCC C R.S. or R.C.E. No. <br /> Test LocatiG Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE. ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ Ch3 <br /> qFY CLEANI, mical�Used/Amount/Mo. <br /> omeowneror Icon agents signature certW91% te"owin_j:"IrertifVthp!In the Perf,rm�rtceefthe work for which this ermitisissued,Ishallnotem to a <br /> in such manr+.2r as to become subject;c x,;ric;r.�;,�:,�.,.rer>>^tin•.�„;, :�'ati', , <br /> P employ any person <br /> Contractor's hirirt� or sub-contracting riTInatura ccrvt;cD <.,,, snl;owing: ; r;t;t,,II, i;n trie per`�rmance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's canpens�:;oa iuws of Calijaruia. <br /> I hereby certify that I have prepar t h i p I i i and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru ations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> _ [/y�� `�+ AMOUNT <br /> FEE _ APO <br /> V/' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />