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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> 1,6,41 APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) �l <br /> y ENVIRONMENTAL HEALTH PERMIT SEP TP GE 1 <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA)�� '4's'ewe = ✓ Address 6; 04,4 e,-,, 4vi <br /> aOwner Address /� <br /> Firm Partners, Addresses and T ephone Numbers _ <br /> a. Business Telephone No. c 47 4�r / / Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) eTitle 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 <br /> 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. _ <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT _ <br /> Job Address/Location �+� f /sl � <br /> Owner FX ` Address 0 CIZI-e !<A _5 o Aa K.D 1 �'r! <br /> ❑ SEPTIC TANK ❑ CESS OOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW -1t(EPAIR ❑ 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 1,000 000 S . Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> d <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 'ati�of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X , <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT K-PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING R MITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE Hsi Y <br /> LESS <br /> PRORATION <br /> PLUS \ <br /> PENALTY 1 <br /> OTHER <br /> OTHER <br /> Q <br /> 9-1a3c. 7 4 <br /> Received by Date Receipt No. Permit No. ..:ante ate Mailed Delive ed <br /> APPLICANT.—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO9kTON,CA 5201 <br />