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Applications Will Be Processed When Submitted Properly Completed. be aures vie• ••• �- <br /> APPLICATION <br /> �NonlerRevocable,and S ( <br /> ENVIRONMENTAL HEALTH PERMIT Cn <br /> U/Jt`om��✓J\ <br /> LIQUID WASTE <br /> Application is reby made t car on b iness'n the juri fictional area of the`jag Joagy)i c�alF th Dist . <br /> Business Name (DB ) s .fit Address 5d 2?41,0 <br /> t�L/�`"y <br /> Address <br /> Owner <br /> Firm Partners, Addresses and Telephone Numbers <br /> © `j Emergency Telephone No. <br /> Business Telephone No. � � <br /> Contractor Licence No.- Title Date n� <br /> .applicants Name (Print) <br /> Please check Applicable Category(1-7)and Fill in the Required nformation <br /> 1. [2 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) - ) <br /> 111 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) CAL. License Renewal No. t <br /> Serial No. CAL. License 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. No. <br /> R.S.or R C.E. Name <br /> Test L ation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Locatippn <br /> _7`�., ntl=&J Address �z <br /> O�w/per ❑ PACKAGE PLANT <br /> lQ SEPTIC TANK LJ CESSPOOL LEACHING FIELD ❑ T ❑ OTHER C <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ` <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 /> Where Certified <br /> Operator Name <br /> Plant Location - ' - <br /> PNo. Units Served <br /> Plant Capacity <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 /> r� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wiW San Joaquin County <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. KVV <br /> �t <br /> APPLICANT'S SIGNATURE X ` <br /> FOR DEPARTMENT USE ONLY `O <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J ary 1 &R i d By January 31 ❑ July 1 S Receiv d By July 31 <br /> BASE EXPLANATION BILLING REMITTAN $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> � p0 ✓ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> Received by Date Receipt No. PerlVt No.� Isauence to Mai Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH ERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Boa 2003 STOCKTON,CA 95101 <br />