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Applications Will Be Processed When Submitted Properly Completed. Be Sure.To Sign The Application. <br /> APPLICATION it <br /> I(F on-Transferable, Revocable, and Suspendable / <br /> t.4VIRONMENTAL HEALTH PERMIT ( SEP7AGE <br /> LIQUID WASTE <br /> Application is hereby�aoe tD arry'ypn�h-usiness in the jurisdictional area of the Sp4oaqui, Local Health District <br /> Business Name IDEA)� 1 r��y��'�G �` � � Address—�` <br /> iowner �, dC1-c__=� Address _ <br /> u Firm Partners, Addresses and Telephone Numbers t ^� <br /> Business Telephone No. - - ,Emergency Telephone No. <br /> Contractor Licence'tJo. �TJ <br /> L Applicants Name (Print) L��� Title _..(' `^ Date <br /> Please check Applidable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30l 19 Disposal Sites <br /> Description(Make/Yr., Color) . <br /> Serial No. CAL. License No. CAE. Liccnse 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. d SANITATION PERMIT , r <br /> Job Address/Location <br /> Owner iAddress7 <br /> ❑ SEPTIC TANK ❑ CESSPOOL Q LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT Q TEMPORARY ❑ NEW ❑ REPAIR h OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 _ <br /> Type Construction Disposal Site <br /> No. of Units I _ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified f" <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7.• ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 0 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/ArAount/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 ragulat':ns yf the Sa k Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE s ❑ EACH' ❑ January 1 It Received By January 31 ❑ July 1 a Reemed By July 31 <br /> REMIT <br /> i, BILLING REMITTANCE S <br /> BASE E%PLAryATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> /� L AMOUNT <br /> FEE A S L� <br /> LESS <br /> PRORATION U <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1 <br /> OTHER - <br /> a�33 ? <br /> Received by Date Receird No. Perm11 No. ! nce batt Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES teat E.H ELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95"1 <br />