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�.- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f ' 'APPLICATION <br /> I (For Non-Transferable, Revocable,and Suspendable) <br /> SEP7AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> L LIQUID WASTE <br /> A licafi hereb�m+ade to on busl ess in the'urisdictional area Of the Jo in Local alth District <br /> r Business Name (DBA) c� � 'J � r 1 Address ox <br /> r a Owner Address <br /> Firm Partners, Addresses and Teie hone umbers <br /> aBusiness Telephone No, Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> L Applicants Name (Print) Title 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 /> - . _--�- �_� — <br /> Serial No. CAL. License No. License Renewal'Np. <br /> Capacity Gal-, Weights &Measures No. <br /> Equipment Parking Address C <br /> 2. ❑ PUMPER YARD 1 1 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> z No. of Chemical Toilets Stored , <br /> i 3. ❑ PERCOLATION TEST e <br /> R.S. Or R.C.E. Name - R.S. or.R,C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner t Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE Pl ❑:PACKAGE PLANT <br /> ❑ PERMANENT C1 TEMPORARY- ' .lid NEW�� 13 REPAIR ❑I OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1` 30, 19 <br /> r 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 /> -1. Plant Location f <br /> Plant Capacity No:`Units Served <br /> 7, ❑ LAUNDRY For July 1, -June 30, 19.— <br /> SIZE: <br /> 9.SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000-Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. '� "Y`"`�" !A <br /> I � t <br /> r � <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, and ru and r laf sof the n Jo uALocal Health District. <br /> APPLICANT'S SIGNATURE X -- <br /> I <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 /> REMIT <br /> BASE EXPLANATIONBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE' DATE REMITTED `` AMOUNT <br /> 1 FEE � —. ` J f <br /> LESS <br /> f PRORATION '2 <br /> f <br /> PLUS <br /> PENALTY <br /> i OTHER.....-.,,.,. <br /> OTHER <br /> X27 <br /> Received by I Date Receipt No.- Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE-,P.O.Boa 2009 STOCKTON,CA 9520] <br />