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mppncauonsWRI tse rrocessedW{ten Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Nott-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i LIQUID WASTE <br /> :4 Application is ereby made to�ar on buslness In the jurisdictional area of the S n Joa uin Local Health District <br /> H business Name (OBA) r f V t Address �• <br /> i <br /> a Owner - _ Address 0Yd AS C7 <br /> zu Firm Partners, Addresses and Telephone Numbers <br /> M Business Telephone No. 7/D i <br /> Emergency Telephone No. ( a <br /> Contractor Licence No. _ <br /> I <br /> Applicants Name (Print) C_.— Title <br /> 7 <br /> Date <br /> Please check Applicable Category (1-7) and Fill in the Regylred Information <br /> 1. © PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal $lies <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal„ Weights 8 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 t _ <br /> 3. C❑ PERCOLATION TEST _ <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Lo ation <br /> Owner LCr Address Aey 7ad', p,yr-icy^ s -" <br /> y� SEPTIC TANK ❑ CESSPOOL K LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAG PLANT <br /> ,w PERMANENT ❑ TEMPORARY ❑ NEW © REPAIR OTHERSU6hps) <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 I <br /> Type Construction Disposal Site - <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July f, - June 30, 10 <br /> Operator Name _._._. Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 __ t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. L <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. eI <br /> i <br /> 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, d rules and regulations of the San Joaquin Local_Health District. <br /> APPLICANT'S SIGNATURE X <br /> l <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER'sl'rE ❑ EACH ❑ January 1 &Received B Januar 31 I <br /> By Y ❑ July 1'&Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT f <br /> D TE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE SAMOUNT <br /> P 7 l7 <br /> LESS <br /> PRORATION - -7/ <br /> r <br /> PLUS +wr / ; <br /> PENALTY I <br /> Aceivedby <br /> ��l 7J77 <br /> pat Receipt No. Permit No. su ce Date Mailed DeliverV <br /> URN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE=S 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />