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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> V iV�0 2 C%a ? APPLICATION yJ <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is herebymade to carry on business in the jurisdictional area of the San,Joaquin Local Health Distrl <br /> FBusiness Name (DBA) . �""� ���'= Address Jli � <br /> z Owner .til f'i /."- j u' Address <br /> C �T- <br /> J Firm Partners, Addresses and Telephone Numbers _ <br /> a. Business Telephone No. _ l Emergency Telephone No <br /> Contractor Licence No. _ <br /> L Applicants Name (Print, <br /> 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. Lic;, 3e Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 - b <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I <br /> 3. ❑ 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/Location �? ,,L�i'� �� �� � 'CV 5 5—IJ <br /> Owner r Address /'n �� -"moi "� �'fa 7e-A <br /> 2'SEPTIC TANK (] CESSPOOL - LEACHING FIELD 11SEEPAGE PIT 13 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ 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 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 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, and rules and re 'onss�. f tt San Jooaaquin 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 July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE u <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> © �3 <br /> V�,/ti/-79 CA <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURNALLCOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />