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Applications Will Be :essed When Submitted Properly Completed. 8 re To Sign The Application. <br /> g171 APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) ___ _ __ __ ___ Address__-_ <br /> c Owner/ ,�7�LQL Z10 40 4__ Address � �-_ - ��t. - — <br /> — — / <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. _-- _ __— Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) '/V �� . / 0�� _— _ TitleDate <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 8 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. 1XMMPERCOLATION TEST <br /> R.S. or R.C.E. Name PAWWR.C.E. No. <br /> -- -- --------— <br /> Test Location P l �` _ '? Test Date/Time 2-�S- �Z i --- —. -- <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location --- - - -- ---- <br /> Owner <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 /> ❑ ORY CLEANING, Chemicals Used/Amount/Mo. --- <br /> I <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. <br /> APPLICANT'S SIGNATURE X x2 � 'J_ _ Title DateFOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT_ <br /> FEELESS <br /> PRORATION PRORATION <br /> PLUS Ap F ✓= jJZ(-/t <br /> PENALTY <br /> YL <br /> OTHER <br /> OTHER C <br /> Re a ved by 6ste Receipt No Permit No Issuance 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 />