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Applications Will Be Processed When Submitted Properly Completed. Be Sbre To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT t <br /> LIQUID WASTE <br /> Application is reby made to -arry on bus' ess in the jurisdic "onal area of the Sa Joaquin Local Health Distri 0 <br /> NBusiness Name (DB - Address. r ��- <br /> aOwner T Address " <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. S7Emergency Telephone No. i <br /> Contractor Licence No. <br /> Applicants Name (Print) Title✓ pate <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 I <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc-fse Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address t <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored b <br /> No. of Chemical Toilets Stored r <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Loc ion a <br /> Owners Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT' -11 TEMPORARY ❑ NEW REPAIR �❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,"-June 30, 19 <br /> Type Construction ' x Disposal Site <br /> No. of Units Equipment Storage/Cleaning <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> i <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4 <br /> >a <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 ruleso regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> l <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT J <br /> FEE �L <br /> LESS ? <br /> PRORATION - <br /> t <br /> PLUS <br /> PENALTY <br /> OTHER _ <br /> a <br /> OTHER t <br /> Received by. Date Receipt No. Perrnit No. Yss once ate ail d Deliver d <br /> ..ANT— (QQ���VVV <br /> APPLIC .—RETURN ALL CO ...ENVIRONMENTAL HEALTH ES" � 1601E.FIA E AVE.,P.O. , STOCK'r01`I, <br />