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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) <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 /> LBusiness Name (DBA) _ Address <br /> aOwner - Address - "'� `" - 411-7 <br /> 7 Firm Partners, Addresses and Telephone Numbers <br /> iBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. - <br /> a Applicants Name (Print) —Title , / Dated <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. Name -_ �� J' j r: R.Sgr R.C.E./No. K! <br /> Test Location �;nMq 40 �7,u2r(A-M FEA,6)I 40 /� Test Date/Time `4/"';/1 f 71f•� <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 /> S. ❑ 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 will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X - Title Date _. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By Jenuary 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION GATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE Q ' Z'I' 7 IL C1- 1 ' � � •IJJ <br /> LESS <br /> PRORATION <br /> PLUS 2 L <br /> PENALTY J <br /> OTHER <br /> OTHER <br /> C� J <br /> Received by Data Receipt No. Permit No. luuance Date Mailed Delivered <br /> APPLICANT—RETURNXLL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.eaa 2009 STOCKTON.CA 95201 <br />