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_ ` C <br /> �- �Applications Will Be Processed When Submitted Proper ybmilted Proper om <br /> ' APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPI AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ma e to carry on business in the jurisdictional area of the San Joaquin <br /> aqu`n Local HealthDistrict t <br /> AppIlcation is hereby Addresses - <br /> Business Name (DBA) Wapp Address <br /> zOwner <br /> a <br /> J Firm Partners, Addresses and Teleph�one�Ncu- ers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. Title Date } <br /> Lame Name (Print) <br /> Please check Applicable Category(1-7) and Fill in the Required Intormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) } <br /> For July 1, June 30, 19 <br /> Disposal Sites ! <br /> Description(Make/Yr., Color) F CAL. License No. CAL Uccnse Renewal Na. <br /> ��---�� <br /> Serial No. Gal.,Weights & Measures No. <br /> Capacity j I <br /> Equipment Parking Address <br /> I 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> I ddd <br /> I No. of Vehicles Stored t <br /> F No. of Chemical Toilets Stored <br /> 3• ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> TesLocation <br /> 4. SANITATION PERMIT -5 <br /> Job Address/Location Address <br /> OwnerHING FIELD ❑ SEEPAGE PIT 13 PACKAGE PLANT <br /> [I ❑ LEAC <br /> V SEPTIC TANK CESSPOOL REPAIR ❑ OTHER', �. <br /> PERMANENT ❑ TEMPORARY ❑ NEW <br /> S• 13CHEMICAL TOILETS For July 1.-June 30.'19 <br /> Disposal Site <br /> Type Construction <br /> Equipment Storage/Cleaning Location(s)No. of Units <br /> C g. ❑ PACKAGE TREATMENT PLANT For July 1,--June 30. 19- Where Certified <br /> t Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. 11 LAUNDRY For July 1,-June 30 El More Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> k <br /> I I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> r <br /> ordinance <br /> laws, and rules an�reg.Lila�ti�ns San Joaquin Local Health District. <br /> k <br /> APPLICANT'S SIGNATURE X <br /> ' FOR DEPARTMENT USE OJan_ NLY <br /> r Jul 5 &Received By July 31 <br /> REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH <br /> REMITTANCE t &Received By January 31AM0❑T DUE CHECKED <br /> BILLING REMITTED AMOUNT <br /> +, v BASE EXPLANATION DATE DATE <br /> a FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> - - Receipt Na. Permit No. <br /> Is9ua ce Date M e4+v <br /> Received by Date } 1601 E.HAZELTON AVE.,P.O. 0:2009 � STOCKTON,CA 85201 <br /> APPLICANT—RETURN ALL COPIES ENVIRONMENTAL HEALTH PERMITISERVICES � <br />