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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) C;E <br /> ENVIRONMENTAL HEAL7EH PERMIT <br /> LIQUID WASTE <br /> Applicatio21j��here ma arry o ,by,s. ess in the I urisdictional area of the San Joa Di t +' � ►ds <br /> Business Name (DBA) _�[LL/� �IYir• Address ' iw <br /> aOwner._ — Addr s <br /> j Firm Partners, Addresses an ele one e ' ! ` <br /> aBusiness Telephone No. _ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) A7FMA7 Title 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 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. XPERCOLATION TES <br /> R.S. or R.C.E. Na a 40 /+ /*//VZf�_ R.S. or R.C.'E... Nco�. 3 �� <br /> Test Location � Alk • IQ • Test Date/Time _ W" 115 SIR-. ! –-ate' il-_ <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 applic iF <br /> d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and yil and reg ti n Joaquin ocal Health District. <br /> APPLICANT'S SIGNATURE X /j/+f --- <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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> P j- <br /> ! / <br /> Received by 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 />