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Applications Will Be Processed When Submitted Properly Completed. Be Sure o Sign aApplication. <br /> APPLICATION ` <br /> (For Non-Transferable, Revocable, and Suspendable) 1 <br /> ENVIRONMENTAL HEALTH PERMIT 5EP7AGE <br /> r LIQUID WASTE <br /> L y Application is hereby made to arty on business in the jurisdictional area of the San Joaquin Local Health District -_ <br /> Grl33usiness Name (DBA) Address .1 1 � <br /> ' z OwnerAddress �� . <br /> a '1 <br /> R Firm Partners, Addresses and Telephone Numbers — - <br /> iL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date �yf <br /> Please check Applicable Category (1-7) and Fill in the Required Information 'V <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) At <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc lse Renewal No. <br /> Capacity Gal., Weights &Measures No. !� <br /> Equipment Parking Address C <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> I[ No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST F '•, <br /> R.S.or R.C.E. No.. `'`t <br /> R.S. or R.C.E. Name <br /> Test Location � Test Date/Time <br /> 4. A SANITATION PERMIT <br /> Job Address/Locations�'L� T <br /> Owner Address <br /> t SEPTIC TANK ElCESSPORL LEACHING FIELD 14 SEEPAGE PIT '❑ PACKAGE PLANT <br /> ,ISI PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑=OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> € Type Construction Disposal Site U <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 /> f� <br /> Plant Location �► <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 +r y S <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> her certify that I have prepared this application and that the work will be done-in accordance with San Joaquin County <br /> 4 ordinances, state laws, an rules and r gul ions of the San Joaquin Local Health District. <br /> I � <br /> APPLICANT'S SIGNATURE X <br /> „. FOR DEPARTMENT USE ONLY <br /> f Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE, ❑ EACH January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATIQN BILLING REMITTANCE $ AMOUNT DUECHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ' <br /> LESS _ <br /> PRORATION - <br /> ' PLUS +' = .�,e;P`^'A �` ,�},� �! + .►' - -".. it 4„ } <br /> { PENALTY ' <br /> OTHER <br /> OTHER <br /> - / <br /> +� <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed e i <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2099 STOCKTON,CA 95201 <br /> C <br />