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Applications Will Be ProcessedWhenn Submitted Properly Completed, 130 SurO To Sign The Application. <br /> APPLICATION �T <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> E-- V)'RISNMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application hereby_made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> �;Business Name ( BA) R 1 o N S Addresses <br /> a Owner Address -:7,47D �ASTJ?.L <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. — 9 <br /> / 0-7 Emergency 7ialephonfa No. <br /> Contractor Licence No. <br /> L Applicants Nai 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 /> 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. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.-S. or R.C.E_ Name R.S. or R.C_I . No. <br /> Test ocation Test Date/Time <br /> 4. A SANITATION PERMIT474-116 i <br /> Job Address/Location <br /> Owner L`Zr2 - <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD I& SEEPAGE PIT PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER <br /> S. ❑ 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 Cerlllled <br /> Plant Location <br /> Plant Capacity 1 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 /> 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 /> I ordinances, state laws, and rulesd re ulations 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 Jufy 31 <br /> REMIT <br /> BILLING REMITTANCE a <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE J -7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by DateReceipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT-..RETURN ALL COPIES TO: JVIRONMENTAL,HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />