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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Reroaal!i3e, and Suspendable) S� , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application iso "hereby ma0e to arry on businessnin the jurisdictional area of the Sant Joaquin Local Health Di trict <br /> v, Business Name (DBA) R. VV S1>°q � I�C� f t 5 SQC. Address 4 U Cal'1C1 � Ve <br /> a Owner HerS ch p 1 TI^R✓/S _ Address 11266 M1 Cr2 Czk;iy-e <br /> u Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. g4Q2 al _ Emergency Telephone No. <br /> Contractor Licence No. c r <br /> a Applicants Name (Print) X21 Title P 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 C <br /> For July 1, _ June 30, 19 M -S 1 102 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ;( PERCOLATION TES S <br /> R.S. or C.E. ame . e R.S. o R.C. No. 17 <br /> Test Location ��i M L%e Erwve Rcu Test Date/Time y`6—9) Ir 3-10 e-/h <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work=d . an Joaquin County <br /> ordinances, state laws,�rules ndreg ation oft e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -li <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 /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE OU AMOUNT <br /> 2 �- oo �q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Re a ved oy Date 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 />