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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) Sr i,-,,, <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 /> v;Business Name (DBA) Address <br /> i Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers -t-�� Z'-� $4rnTZ_1�5 13q-,5 <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) 4 Title zn� 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 � 1 ' <br /> 2. 1:1 /�/ <br /> PUMPER YARD !. ' ' �2' M6 v <br /> For July 1, June 30, 19 • AI,t G� <br /> No. of Vehicles Stored <br /> No. off Ch'�ical Toilets Stored <br /> 3. PERCOLATION TEST \ CQ <br /> R.S. or R.C.E. Name �� �� �Z�rJ R.S. or R.C.E. No. ZR 0-5 <br /> Test Location 006n:> p �� Test Date/Time D�>✓( Tom—( <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 F- <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, r les a dlations`pf a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLA !> P DATE DATE EMITTED AMOUNT DUE CHECKED <br /> /�/ �/ q �] 7 G (.� AMOUNT <br /> FEE lV(p lt'Jl. }� "fes l�J�l� � /l "'i <br /> LESS <br /> PRORATION <br /> PLUS Z <br /> PENALTY <br /> OTHER <br /> OTHER �j <br /> Rec ed 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 />