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f Applications Will Be Processed When Submitted Properly Completed. BeSureTo sign ineAppncauVII. <br /> APPLICATION } <br /> (For Non-Transferable,'Revocable,}and Suspendable) 5E1'TAGE / <br /> 2 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is her9by made to on business in the jurisdictional area of the Sa4Joaquin.Local Health District air: <br /> y Business Name(DBA) _. r—�� Address <br /> r <br /> a Owner � - ,.� Address <br /> 9 Firm Partners,Addresses and Telephone Numbers <br /> aBusiness Telephone No. - Emergency Telephone No. ti <br /> a _ <br /> Contractor Licence No. _ <br /> LAPPlicants Name (Print) ;,. y. .__ Tit! DateK <br /> e _ . <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 -- -=June June 30,-19 = = Disposal Sites - <br /> Description(Make/Yr., Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal.,-Weights & Measures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> I k <br /> For Juiy'1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Ck emical Toilets Stored <br /> - +. ..T - r <br /> 3. ❑ PERCOLATION TEST i <br /> } R.S. or R.C.E.Name R.S.or R.C.E. Nb. i <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMITa ' <br /> Job Address/Location 1� <br /> 765 — AdClress <br /> Owner <br /> 9-'eEPTIC TANK 9?'CESSPOOL ❑.LEACHING FIELD -0 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ f <br /> ❑ PERMANENT 11TEMPORARY ❑ NEW REPAIR 13 OTHER � G <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ,. <br /> S F' <br /> Type Construction Disposal Site <br /> p ' . <br /> No. of Units Equipment Storage/Cleaning <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19--, Where Certified <br /> OperatoriNamert1-r <br /> Plant Location ' <br /> Plant Capacity No. Units Served <br /> � <br /> I 7. ❑ -LAUNDRY For July 1, -June 30, 19 - - <br /> .SIZE: I❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sgt.rt t _ <br /> ❑ DRY GLEANING.Chemicals Used/Amount/Mo. <br /> 4. _ .-: �.: ��!" �to 4,,,,, .v ` a n. _ - - - -•- .- _ j- <br /> ' 1 <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 rules and�re ulations of the San.Joaquin Local Health District. j <br /> APPLICANT'S SIGNATURE X <br /> , I ' <br /> FOR DEPARTMENT USE-ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SIT '. �"0'-EACH -J❑ January 1 8 Received By January 31 ' ❑ July 1 &-Received By July 31 <br /> • � �REMIT <br /> /'BASE <br /> BILLING REMITTANCE € AMOUNT DUE CHECKED <br /> EXPLANATION REMITTED AMOUNT <br /> DATE i <br /> FEE _ . - - .- <br /> LESS - - - F - <br /> PRORATION <br /> I PENALTY' : <br /> t <br /> OTHER <br /> U1 ,Received,by Date 1 Receipt No. _ Permit No, f ssuanc Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: "ENVIRONMENTAL HEALTH PERMIT/SPRVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />