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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) SEPTATE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is he eby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA . , F' <<P!'-f-� Address <br /> aOwner r. C� =r_3� F �__ ' Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. j/ Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title '�`,.sJ?� f Date — _ ✓�` �1 <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. License 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 7 ' "''r <br /> 3,--> <br /> Owner Address — <br /> M-'SEPTIC TANK ❑ CESSPOOL 21LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY VIEW ❑ 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 Fort—July,_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. C„I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. _ <br /> 7 <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 ations f the San Joaquin Local Health District. \ <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY J <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 C <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> t 180 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ance ate Mailed De#Wfed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST CKTON,CA 952 <br />