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Ap`MicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTALFIEALTH PERMIT SEETAGE <br /> LIQUID WASTE <br /> A licati n I h e �r�ade o car business in the'ur'.dictional area of the San a uin L at , alth District <br /> y Business Name (DBA) } �yI L(' carry >nCx i�ue f �-4C_ Address ��� t' ' ' <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers 823-, cz&{r <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. �� %�8 <br /> L Applicants Name (Print) j � Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 5 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL, Li:..:,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 LWation Test Date/Time <br /> 4. L`9 SANITATION PERMIT/�f <br /> Job Addres Location (,t.�, S r,ia14 Yr' <br /> Owner &I )I ) y'Q Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT '•!► <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 2REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 _ <br /> Type Construction Disposal Site 4,0o Aie� _ 7up I u <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 1,004 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared this application and t t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and s and regulations of the Sa aquin Local Health District. <br /> CCL <br /> APPLICANT'S SIGNATURE X I-, �� �` If <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 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -� I � . <br /> Receivell by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1$01 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA <br />