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!` y <br /> i Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ! <br /> _ APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) $EPTAGE <br /> €I ENVIRONMENTAL HEALTH PERMIT <br /> i+ LIQUID WASTE ^� <br /> + 1 l <br /> ly Appl icati is ereb ade to carry on busines in the jurisdictional area of the�jSa 9 oaaq cal Health District <br /> Address� �"`—�� <br /> F Business N e {DB) ) - . <br /> a Owner <br /> Address <br /> 9 Firm Partners, Addresses andTe phone Numbers <br /> G. Business Telephone No. ZI (K— 4;' 7 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) c Title Date r <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. GAL. 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. No. <br /> R.S. or R.G.E. Name CA <br /> Test Location Test Date/Time <br /> 4. ❑. SANITATION PERM T <br /> Job Addres /Location <br /> Own 7340 <br /> Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 1:1LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11PERMANENT C1TEMPORARY 11 NEW ❑ REPAIR ❑ OTHE�� <br /> 5. ❑ 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 <br /> Where Certif led <br /> Plant Location <br /> " No. Units Served <br /> Plan;Capacity <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 /> I; <br /> :k <br /> II <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 re `la io of the an Joaquin Local Health District. <br /> is <br /> APPLICANT'S SIGNATURE X ' <br /> I <br /> 3 <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY [3 PER UNIT ❑ PER SITE El EACH El January 1 &Received ey January 31 El July 1 &Received By July 31 <br /> REMIT <br /> it BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS 6 <br /> PRORATION i <br /> PLUS <br /> PENALTY <br /> Ila OTHER <br /> OTHER <br /> I� �1 f' <br /> I� Received by Date Receipt No. Permit No. Issualice D to Mailed elivered C <br /> I <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOGKTON,'CA 952 <br />