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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ' <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SI PTAGE <br /> LIQUID WASTE <br /> Appl icatior s hereby�to car on business in the jurisdictional area of the San Joaquin Local Heal Di trict <br /> rBusiness Name(DBA) ,/Y�/p — /T2547AW �.FIPI/�L° Address S <br /> a Owner R LJe�c�/ Address D S <br /> J Firm Partners, Addresses and Tel hone Numbers <br /> aBusiness Telephone No. `���� Emergency Telephone No. <br /> Contractor Licence No. -- <br /> i -Q ' 1 Q <br /> Applicants Name (Print) Title *Sr Date <br /> f 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. Licznse Renewal No. <br /> Capacity Gal., Weights & Measures No, <br /> C Equipment Parking Address <br /> 2. ❑ PUMPER.YARD <br /> For July-1,_ June 30, 19 <br /> No, of Vehicles Stored <br /> I, No, of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> f Test Location Test Date/Time p <br /> 4. 0 SANITATION PERMIT f f3 � (- 7 � ti <br /> Job Addr s/Locatio �'�� <br /> Owner J� �Lb t Address SY451– M �'/L� <br /> q ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 'SEEPAGE PIT ❑ PACKAGE PLANT 6N <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction I Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> f Operator Name Where Certified <br /> Plant Location <br /> # Plant Capacity 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 /> I <br /> I 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, a 13s and r ula ions of the Sa Joaquin Local Health District. <br /> k APPLICANT'S SIGNATURE X + <br /> I � <br /> FOR DEPARTMENT USE ONL-Y­ <br /> Fee Is Due:.❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 C July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE iEXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> r AMOUNT <br /> FEE d 10 ' <br /> ILESS <br /> PRORATION '� i l;i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1. OTHER <br /> i <br /> Received by Date � t, Receipt No. Permit No. ssua ce Date Mailed Delivered 'r <br /> APPLICANT—RETURN ALL COPIES TO: ?'ENVIRONMENTAL HEALTH,PERM ITISERVICES 1601 E.HAZEL AVE.,P.O.Box 2069 .STOCKTON,CA 96201 r <br />