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n Submitted Properly Completed. Be Sure To Sign The Application. <br /> Appl}cagona Will a_ <br /> APPLICATION <br /> L tFor Non-Transferable, Revocable, and Suspendable) <br /> 76 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application <br /> om-isohereby made to carry on business in the j isdi ti nal area of the San Joo/aquin Local Health District / /� <br /> y Business Name (DBA) __-_- 1-�_`' Address,///--> <br /> z Owner - - - - --. _ Address--- <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. — Emergency Telephone No. <br /> Contractor Licence No. /:' -" 3 z <br /> C <br /> a Applicants Name (Print). 4 a Cl _ �/ LAS Title ��� ��9 � r Date -7–2 �/ <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 /> -;�:S yr R.C.E. Name v dsiC R-& R.C.E. NO. <br /> Test Location 1 ✓+5'.''/f��%r _ Test Date/Time_-�7– 2 �� <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 will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X ^J� J .` _ Title r /ts/ ! /�'i% Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 a Received By July 31 <br /> —1 REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE !OV° 'ut� -• '/,3' / L � J �o,tic3 ��7�j� <br /> LESS d <br /> PRORATION <br /> PLUS <br /> PENALTY �i✓C aSS�- / - <br /> OTHER �� Cl,�4 �u`/ r - --- <br /> OTHER <br /> /o - <br /> Race 1 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.Boa 2009 STOCKTON,CA 95201 <br />