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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) <br /> ENVIRONMENTAL HEALTH PERMIT SI PTAGE <br /> LIQUID WASTE <br /> k Application is by made to c ry o bus' ss In the juri ctional area of th 0 J quin Local H alth (mss, t <br /> y Business Name (DBA)��. U�Address I C C��l � � �0 <br /> z Owner Address <br /> e <br /> J Firm Partners, Addresses and Telep n Nu ers <br /> aBusiness Telephone No. 6r� 60-7 Emergency Telephone No, <br /> Contractor Licence No. <br /> < Applicants Name (Print) Title Date Q <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 /> Te s ovation Test Date/Time <br /> I 4. �SANITATION PERMI <br /> Job Adds/Lo atio L <br /> Owner431 <br /> Addres O <br /> SEPTIC TANK ❑ CESSPOOL Id� LEACHING FIELD 13 SEEPAGE PIT ❑ PAC GE PLANT (� <br /> I PERMANENT 11 TEMPORARY )11 NEW ❑ REPAIR ❑ OTHER "a <br /> { ' <br /> 5. 11 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 For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> I' <br /> Plant Location '. I <br /> Plant Capacity No. Units Served <br /> tI 7. ❑ LAUNDRY For July 1, -June 30, 19 I <br /> t SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. : : <br /> I, <br /> LJ✓3 <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 n Iulati o theS aquin Local Health District. <br /> APPLICANT'S SIGNATURE X r <br /> C oS <br /> FOR DEPARTMENT USE ONLY <br /> 4 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ FAC N ❑ Januaryj1 &Received By January 31 [1 July 1 &Received By July 31 <br /> BILLING REMITTA $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> AMOUNT <br /> FEE r O <br /> LESS <br /> t PRORATION <br /> PLUS <br /> + PENALTYcK <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I Iss ance ate Mailed Delivered <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELT VE.,,P.O.Box1009 STOCKTON,CA 95201 <br />