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s Applications Will Be Processed When Submitted Properly Completed. Be SureToSign ineAppncanvrr. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) S�PTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> hereby made to carry on is business in the jurisdictional area of the San Joaquin Local Health District <br /> Applicationj <br /> r is 5,0/V:5 Address <br /> Business Name (DBA) <br /> z Owner i <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. v <br /> Contractor Licence No. O <br /> Title 77 Date <br /> L Applicants Name (Print) . <br /> 5Ti9�t3C.�y �idl'S �S <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. C1PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> I <br /> For July 1, June 30, 19 Disposal Sites p <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. 1 CAL: License No. <br /> Capacity Gal.,Weights &Measures No: <br /> Equipment Parking Address ' <br /> 2. ❑ PUMPER YARD I Q <br /> For July 1, June 30, 19'- <br /> No. <br /> 9r-No. of Vehicles Stored <br /> No. of Chemical Toilets Stored _ t <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. Na <br /> R.S.or R.G.E. Name . <br /> Test Location Test"Date/Time <br /> 4. 2-SANITATION PERMIT •^ j <br /> Job Address/Location <br /> �T <br /> Address <br /> Owner <br /> L�5, EPTIC TANK ❑ CESSPOOL lJa/LEACHING FIELD IrSEEPAGE PIT CI-PACKAGEACKAGE PLANT ,.+. <br /> EI/SPERMANENT ❑ TEMPORARY 0EW ❑ REPAIR ❑ OTHER <br />' 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> # Disposal Site <br /> Type Construction <br /> No. of Units '.. Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 , <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity r No. Units Served <br /> t 7. ❑ LAUNDRY For July 1, -June 30, 19 ! <br /> t - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. i <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I, <br /> } <br /> r/,( zI� <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, a rules and gulation f t Joaquin Local Health District. w <br /> APPLICANT'S SIGNATURE - <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY - ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> k BILLING REMITTA S AMOUNT IDUE CHECKED <br /> BASE EXPLANATIONREMITTED AMOUNT <br /> _ --pATE�- p _ <br /> ( FEE - [-�5 #. z <br /> k LESS c <br /> PRORATION I _ , ,g <br /> PLUS # <br /> i PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> 'Date Receipt No. Permit No. - - I uance ate .Mailed <br /> Rec ived by Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2008 STOCKTON,CA 95 - <br /> _�3 <br />