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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheAPpticauon.Y 4•r' <br /> APPLICATION 'r l <br /> (For Non-Transferable, Revocable,-and Suspendable) S PTAGi , war <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatis hereb maT t rry on business in the jurisdictional area of th San J oaq inLn Local_Health Distrjret � <br /> Business Nam= (DBA} Addressx C•� <br /> . .L:,.. Address - <br /> z Owner _ <br /> 9 Firm Partners,'Addresses-and elephone Numb <br /> a 6 , Emergency Telephone No. <br /> IL Business Telephone No. - - <br /> Contractor Licence NO. - _ <br /> �Applicants`Name!(Print) Title. 7 Date I <br /> Please check Applicable Category (1'-7) and Fill in the Required Informatlon <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) V <br /> For July 1, June 30, 19- Disposal Sites <br /> a <br /> Description(Make/Yr., Color) K <br /> " CAL. License Renewal No <br /> Serial No. GAL. License No. <br /> Capacity t Gal., Weights & Measures No. <br /> Equipment Parking Address s <br /> 2. ❑ PUMPER YARD , <br /> For July 1, F JLITIA0, 19 ``t <br /> No. of Vehicles Stored E . .; �_.� . .t i <br /> No. of Chemical ToiletsStored''r'' t I <br /> 3. 1:1PERC6LATION4EST I ) <br /> R.S. or R.C.E. Name ; f R.S. or R.C.E. No. <br /> Test Location( �= _ Test Date/Time <br /> ..w <br /> 4.,-IWSANITATION PERMIT +. <br /> Job Add s/Location e %319-:11%. <br /> .� <br /> Owner Address <br /> ❑ SEPTIC TANK ® ESSROOL �LEACHING FIELD ❑ SEEPAGE PIT ❑ C'ACKAG PLANT j <br /> XPERMANI NT 0 TEMPORARY ❑ NEW XREPAIR OTHER �f <br /> 5. ❑ CHE=MICAL TOILETS For July 1, June 30, 19 f _ <br /> a Site <br /> Type Construction Disposal F <br /> No. of'Unitsa i � Equipment Storage/Cleaning Location(s) a°ice <br /> 6. 1:1 PACKAGE TREATMENTPLANTorJuiy 1 -June 30, 19, <br /> Operator Name ;-- - '' t. tr4 Where Certified <br /> Plant Location <br /> Plant Capacity E No. Units Served <br /> 7. ❑ LAUNDRY For 1411, - une 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals lased/Amount/Mo. t <br /> i11 be done in accordance,with'San Joaquin County <br /> I hereby certify that have prepared this application and that the work w <br /> ordinances, state laws, and rules and re lal n of a San Joaquin Local Health District. _ <br /> APPLICANT'S SIGNATURE X f r . -- <br /> 7' i <br /> '',� � -� 1„�t'•j. FOR DEPARTMENT USE ONLY 1 <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT>',71❑ PER SITE _/❑ EACH -E] January 1 &rieceiveddRy January 31 ❑ July 1 &-Received By July}31 <br /> �" REMIT <br /> '.BILLING REMITTANCE AMOUNT OUF CHECKED <br /> BASE FXPLANATION ;,- PATE -DATE REMITTED AMOUNT <br /> i <br /> FEE .. �Sf <br /> LESS <br /> PRORATION r" <br /> PLUS F <br /> PENALTY �- <br /> OTHER <br /> OTHER <br /> Receivedeby Date Receipt No. � - Permit Nv. I55 nc ate Mailed Delwere F <br /> APPL16ANT—RIETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVIL�EF�`��� -1601 :HAZELT .,P.O.Box 2009 STOCKTON,C, 95201i- <br />