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_..__A .. Properly � ... 1 <br /> z.' Applications Will Be Processed When Submitted <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and SusQendable) S�PTAG� <br /> ENVIRONMENTAL HEALTH PERMIT if1 <br /> LIQUID WASTE <br /> LBA)atio s hereby m, to car � sine sin.-the Iur��otionalgadrderessthe San Joaquin cal Hea Distrlc <br /> ��® � ELyBusiness NameAddress <br /> i Owner <br /> .9 Emergency Telephone No. <br /> 2 Firm Partners, Addresses and T I hs e Numbers <br /> I 0E Business Telephone No. Date r a <br /> A Contractor Licence No. Title ' <br /> Lapplicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VENICE „k <br /> June 30, 19 Disposal Sites kA <br /> For July 1, 4- <br /> CAL. License Renewal No. <br /> r Description(Make/Yr., Color) CAL. License No. <br /> f. Serial No. <br /> Gal.,Weights &Measures No. <br /> 4 Capacity <br /> Equipment Parking Address <br /> 2• ❑ PUMPER YARD <br /> k For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> I No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S. or R.C.E.No. I <br /> R.S. or R.G.E.Name Test Date/Time " <br /> Test Location �e7Cd <br /> f q• INSANITATION PERMIT �� <br /> Job//Address/ ocation Address <br /> OwnerPACKAGEPLANTC SSPOOL LEACHING FIELD �SEEPATGpj^1❑ OTHER ; <br /> SEPTIC TANK fikNEW ❑ REPAIR _ II <br /> I PERMANENT El TEMPORARY :f <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> I Type Construction <br /> Equipment Storage/Cleaning-Location(s) <br /> No. of Units <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served I <br /> I <br /> Plant Capacity <br /> I 7, ❑ LAUNDRY For July 1, -June 30, 19 <br /> 000 Sq. Ft., [3More Than 1,000 Sq. Ft. <br /> SIZE: 11 Less Than 1� <br /> 13DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i <br /> ordinances, state laws, a ru sand regulation of the Sa oaquin Local Health District. <br /> F APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY i <br /> ❑ July 1 &Receivedy 31 <br /> • 1 <br /> Fee IS Due: ❑ ANNUALLY � ❑ NIT PER SITE EACH ❑ January 1 &Received By January 31 <br /> PER U ❑ REMIT <br /> 3 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKEDI <br /> BASE <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> I <br /> FEE �lS CI• SII <br /> LESS <br /> r PRORATION <br /> PLUS <br /> PENALTY e <br /> OTHER <br /> k G1: <br /> OTHER <br /> Permit No. Issuance Date Mailed Delivered <br /> Date + Receipt No. <br /> Received by 1501 E.HAZELTON AVE:,P.O.Box 2009 STOCKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM17/SERVICES <br />