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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. , <br /> APPLICATION <br /> Qor Non-Transferable, Revocable, and Suspenda <br /> ENVIRONMENTAL HEALTH PERMIT <br /> '- € ''`� <br /> LIQUID WASTE <br /> Appl icatio s h eby de rry usI a In the jurisdictional area of the San Joaqui Local Health istrtct /J ` <br /> H Business e (DBA) i<G�� _ Addr ss—�Ca ✓ [�� <br /> z Owner �[� Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 26-P39>.3-1-3 _._ Emergency Telephone No.j/4/A-4— <br /> Contractor Licence No. 0S-7-41 <br /> Applicants Name (Print) «� atzl'E Title Date 5 �� <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 R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. WISANITATION PERMIT <br /> Job Addre /Location r �OtJ�tg100.c <br /> Owner _ 4� Lt�i.�t-�, Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 9-LEACHING FIELD EYSEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ®'REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 L' } <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 C) <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 _ <br /> SIZE: Cl 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, a ules an�gns the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S1TE ❑ EACH ❑ January 1 8 Aeceived By January 31 ❑ JWy 1 S Received Ry July 31 <br /> BASE 7 EXPLANATIONP <br /> BILLING REMITTANCE S REMIT <br /> ATE DATE REMITTED AMOUNT DUE• CHEVED <br /> -..l A�^i'p-jU <br /> FEELES <br /> PPRO <br /> RORATIpN <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> Received by Date Receipt No, Permd No, Issuaince Da a Marled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />