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Applications <br /> Will Be Processed When Submitted Properly Completed. BeSurenio alga I'M <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) n SI_PTAGE I ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ? <br /> Application is ereby made o carry on business in the jurisdictional area of the San �o�aq Local Health District <br /> r <br /> kL Address <br /> H Business Name (DBA) <br /> Address <br /> z Owner <br /> Firm Partners, Addresses and Teleph %ef rs Emergency Telephone No. <br /> aBusiness Telephone No. ZZ� <br /> Contractor Licence No. � Title — `"` Date �a' "` `7� <br /> Applicants Name (Print) ` <br /> Please check Applicable Category (1-7)and Fill in the Required Information I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. LiI:,nese Renewal No. <br /> Serial No. CAL. License No. <br /> I Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Storedr <br /> 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 /> Test Location <br /> 4. ❑ SANITATION PERMIT ?iL <br /> Job Address/Luca 'on �� 3 �' + ��°' 4:1 �!4�3"?1 <br /> Address Q <br /> Ow er ❑ PACKAGE PLANT <br /> EPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT 13 OTHER <br /> ❑ TEMPORARY `REPAIR <br /> PERMANENT ❑ NEW _ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> { <br /> Disposal Site <br /> Type Construction <br /> Equipment Storage/Gleaning Location(s) <br /> No. of Units <br /> + g. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified <br /> Operator Name <br /> i Plant Location <br /> No. Units Served <br /> Plant 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 /> certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I hereby <br /> ordinances, state laws, and rules and regulations of the S aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:'❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &ReceivedREMIT <br /> uIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER } <br /> OTHER <br /> 3\ <br /> ''ZIIIII 11116 <br /> Issuance D to Mailed Delivered <br /> Date Receipt No. Permit No. � <br /> Received by 1601 E.HAZELTON AVE.,P.O.Box 2009. <br /> APPLICANT—RETURN ALL COPIES TOSTOCKTON,CA 9 01 i <br /> : ENVIRONMENTAL HEALTH PERMIT/SERVICES <f 7/�f. <br /> 1 � J - <br />