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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheApplication. <br /> APPLICATION <br /> '^ (For Non-Transferable, Revocable,and Suspendable) l <br /> ENVIRONMENTAL HEALTH PERMIT SEP <br /> LIQUID WASTE <br /> Application is tMre y m d to r n u in ss V he juridi tional area of th at aquin L al H It District <br /> HBusinessName (DBA) d r ss <br /> a Owner <br /> yy l .E W,F� Address <br /> Firm Partners, Addresses a gl ho e N mb rs <br /> aBusiness Telephone No. Emergency Telephone No. fy� <br /> i Contractor Licence No. <br /> LApplicants•Name (Print) Title Y 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. Liccnse Renewal No. <br /> CA acity "' """ Gal:,'Welights &Mbasures,1•io-- <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored - ---.__ - , _ ­ _ q <br /> Noi of Chemical Toilets Stored <br /> 3. "❑ PERCOLATION TEST ! <br /> R.S. or R.C.E. Name R.S. or R.C.E. NO. i <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PER911�f9O — 5 l <br /> Job Add s/L ation ��f <br /> O nerI EO <br /> Address M E� a <br /> '`SEPTIC TANK ❑ CESSP.00L NEV LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY PiEW ❑ REPAIR ❑ OTHER `C' <br /> 6, <br /> 5. ❑ CHEMICAL TOILETS •F&July:1,-June 30, 19,_.,,. f 5 <br /> Type Construction r 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 S <br /> SIZE: © Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certift I have prep d this applicati and that the work will be done in accordance with San Joaquin County <br /> ordinances, st to la and rules an regula 'on of a San.Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Y Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE' g REMIT <br /> BASE EXPLANATION _ DATE DATE. REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ( 47 y[ � S <br /> LESS <br /> PRORATION <br /> PLUS U <br /> PENALTY <br /> OTHER / <br /> OF!-kER 1000" 1 <br /> �o `7ZV 3��y o&36'7 `7/�/� <br /> Y_ <br /> Received by Date Receipt No: Permit No. Issuance Date Mailed Delivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95291 <br />