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c-0A k_ 4 lications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �' � APPLICATION ,( <br /> ( ( (For Non-Transferable,Revocable,and Suspendable) „S1 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i3.hereby made to carry,on business in the jurisdictional area of the San Joa uin Local Health District <br /> OF Business Name (DBA) A �'� �5'�`�'/ Address 4:;';00 ':5 Ul <br /> Owner '�q'UAddress -AAQL5- <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. '� _ / 7 Emergency Telephone No. <br /> Contractor Licence No. f � _ <br /> L Applicants Name (Print) "4'.z'`� zl'L:'C� Title X6 E_ � '` 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;;:-.se Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD M <br /> E For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. a <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERULT <br /> Job Address/Location ='�' 1 •� �� sr <br /> O�w�ner Address ., <br /> L'1 SEPTIC TANK ❑ CESSPOOL 9�-T_€ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ~ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER _ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 L <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 Iatio f the San Joaquin 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS IQ <br /> 1� <br /> PENALTY ♦ <br /> OTHER <br /> OTHER <br /> U3 <br /> Received by Date Receipt No. Permit No. I suance DaVe Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O,Box 2009 STOCKTON,CA 95201 <br />