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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> F (For Non-Transferable, Revocable, and Suspendable) <br /> SEPT AGE <br /> II ENVIRONMENTAL HEALTH PERMIT <br /> ' LIQUID WASTE <br /> Application i hereby ma to carry n business in the i risdictional area of the San Joaquin Local Healt istrict <br /> F Business Name ;an�d�Tel�ephone <br /> a� _11 Address—� '. -� <br /> z Owner r Address <br /> t 9 Firm Partners, AddresseNumbe <br /> Sr! <br /> 0.4 Business Telephone No. Emergency Telephone No. <br /> -` <br /> Contractor Licence No. <br /> � <br /> Applicants Name (Print) Title Dale <br /> ' Please check Applicable Category(1-7) and Fill in the Required In mation <br /> 1. ❑ PUMPER VEHIC.LE�PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,i �Juune30, 19� Disposal Sites <br /> Description(MAke/Yr:,Color)A. <br /> Serial No. CAL. License No. CAL. License Renewal NO. <br /> IV� <br /> Capacity`"'!` ` Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 h <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored i1 _ <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> -4 st Date/Time <br /> Test Location - ^ <br /> r <br /> 4. ❑ SANITATION PERMIT 1 e• <br /> Job Addre ocation <br /> Owner Address <br /> E] SEPT SEPT ANK CESSPOOL LEACHING FIELD IT ❑;PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORA,RY ❑ NEW REPAIR ❑OTHER <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction IF Disposal Site <br /> No. of Units Equipment Storage/Clears ng Location(s) <br /> s f <br /> 6. © PACKAGE TREATMENT,;PLANT For July 1,'=June 30' 1� , <br /> Where Certified ' <br /> Operator Name / <br /> Plant Location <br /> No Units Served <br /> Plant Capacity ' >fl <br /> 7. ❑ LAUNDRY For July 1, -.June 30, 19 ( <br /> J <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 4 G� <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Ir <br /> li <br /> :I <br /> I hereby certify that l have prepared this application and that the work-will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru and re ion the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE 1i <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Re PER By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED (� AMOUNT <br /> FEE 1 f <br /> LESS II <br /> PRORATION I, <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> n. <br /> J. <br /> OTHER <br /> Q53i3 � - �-tea <br /> Received by Date Receipt No. Permit No. suance 0 e Mailed Delivered <br /> } __- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES '1601 E.HAZELTON .,P.O.Box 20o9 STOCKTON,CA 9520 <br />