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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) <br /> rt" ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ishereby made to car on business in a <br /> ness Name (DBA) jurisdictional area of the San Joaquin Local Health D' trict <br /> Z A C+-A N-: C...e�¢_.m._�\ K' Address <br /> rBsi <br /> i Owner vw_Q1 Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers SZZ-R 1 Z 2 <br /> a. Business Telephone No. Emergency TelephoneNo. <br /> Contractor Licence No. 71 it� <br /> L Applicants Name (Print) o Title Date 2 <br /> Please check Applicable Category(1-7)and Fill in the Required Informati n <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.Zf <br /> Vehicles Stored <br /> No. Chemical Toilets Stored <br /> rQ3 PERCOLATION TEST �'�� r C 7�d� 00.OS. or R.C.E. Narpq R.S. or R.C.E. No. <br /> Test Location QMLT1 kid-ADA Er,4*?]ETest Date/Time <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 <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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> // �7, AMOUNT <br /> FEE `JG.1,c7 � tO ✓J (00,0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 4• <br /> .Aeceivdd by Date Receipt No. Permit go. Issuance Date Mailed Delivered a <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />