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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> -; V APPLICATION <br /> (r ^"� (For Non-Transferable, Revocable,and Suspendabie) ` <br /> ENVIRONMENTAL HEALTH PERMIT SEPPAGE I <br /> LIQUID WASTE 4 <br /> Applic is hereb ade to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name ( ) Aw (JjC L Address <br /> aOwner C Address . �. <br /> 2 Firm Partners, Addresses and Tel <br /> rlp,Numbers <br /> a. Business Telephone No. +r s i Emergency Telephone No, <br /> Contractor Licence No. <br /> 4 Applicants Name'(Print)'R'-� 4641WTitle���+ <br /> Date <br /> k. Please check4Applicable Cat gory(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER@VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />,. For July 1,t''' 4 ''June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br />` Capacity Gal., Weights & Measures No. <br /> I <br /> i Equipment Parking Address <br /> k 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 /> A <br /> R.S. or R.C.E. Name l R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION.PER I <br /> Job Address/Location <br /> Owner S. ddress <br /> p ❑ SEPTIC TANK I ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑'PACKAGE LANT 'z. <br /> ❑ PERMANENT TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. C] CHEMICAL TOILETS For July 1, -June 30, 19 <br /> r t' _ <br /> Type Construction r Disposal Site <br /> No. of Units i :r Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For.-July 1,;=.June,30, 1' <br /> Operator Name r r' ! Where Certified <br /> Plant Location ( i <br /> Plant Capacity ^ No. Units Served <br /> I <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than71`000 Sq. Ft-. ❑ More Than 1,000 SgJFt. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. E <br /> If <br /> I hereby certify that I have prepared this application and that the work well be done in accordance`with-San Joaquin County ` <br /> i ordinances, state laws, a es regulations of th° San Joaqui Local Health District. <br /> i <br /> APPLICANT'S-SIGNATURE X <br /> { FOR DEPARTMENT USE ONLY <br /> i �� '' <br /> Fee IS Due: Eli ANNUALLY ❑.PER UNIT ❑ PER SITE t 11 EACH _ �January 1 &Received By,January31t El July 1 &Receiived By July 31 t <br /> ""w'• .«. s . z. r REMIT ; <br /> r 4 BASE t EXE. BILLING REMITTANCE $LANATION DATE OA7E REMITTED AMOUNT DUE (CHECKED. <br /> ,AMOUNT 1 <br /> r FEE <br /> )LESS <br /> fI ,PRORATION _ F ._ -....--,.. .,, ...„� <br /> /c f <br /> PLUS' _ ��- <br /> yPENALTY <br /> OTHER <br /> -'OTHER+ .•� # - <br /> �. .. <br /> -- Received by r Date - Receipt No. Permit No issuarrice Dade Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1501 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON;CA 9520 <br />