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1-illv licatiens Will Be Processed When Submitted ProperlyCompleted.UeSure 10sign ImeP"Pp,wauene <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEETAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE t <br /> Appl ica'old+s hexeh made to carry on business in the jurisdictional area of tFle rLJoay�uin cal H t istrict <br /> �, 1,47 <br /> Business Name SA)- fti ��e� Address ] ? <br /> aOwner Address <br /> j Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No-- _Emergency Telephone No- <br /> i Contractor Licence No. <br /> LApplicants Name(Print) - r, Title — — Dale <br /> Please cheat 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.,Colon_ <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 C <br /> R-S.or R.C.E. Name _ R.S.or R.C.E.No- <br /> Test Location <br /> 1 Test Date/Time T <br /> 4. 0 SANITATION PERMIT <br /> Job Address;Location <br /> Address <br /> SEPTIC TANK ❑ CESSPOOL E HING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT r t <br /> ❑ PERMANENT ❑ TEMPORARY _ EW ❑ REPAIR ❑ OTHER r` <br /> 5. ❑ CHEMICAL TOILETS For Juiy 1,-Jun;30,19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Starage/Cleaning Location(s)- <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name _ Where Certified <br /> Plant Location <br /> Plant Capacity T _No.Units Served <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 /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and rer lati'o f the San Joaquin Local Health District. <br /> i <br /> APPLICANT'S SIGNATURE Y+ <br /> r _ <br /> FOR DEPARTMENT USE ONLY R <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ danuw 1 B Received 8y January 31 ❑July 1&neceivec Ely July 31 <br /> REMIT <br /> BASE EXPLANATION 61LLING REMITTANCE E AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 41- <br /> � � <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 01HFR rn — <br /> Received lly Dale Receipt No. Permit No. I ance a Mailed Delivered <br /> 1 — ALP PLIC ANT—FIETURN ALL COPIES TO-. ENVIRONMENTAL HEALTH PERM1TISERVICES 1601 E. AIELTOH AVE_P.O.Boa 20M STOCKTON.CA 95201 - <br />