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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSign TheAppRcauon. <br /> APPLICATTON <br /> (For Non-Transferable, Revocable, and Suspendable) SE:PSAGE <br /> ENVIRONMENTAL HkALTH PERMIT II <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District TI <br /> Or Business Name (DBA) Address +r <br /> ? Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0. Emergency Telephone No. <br /> a Business Telephone No. - <br /> Contractor Licence No. <br /> Title Date <br /> Applicants Name (Print) <br /> Please check 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 ..,y <br /> Description(Make/Yr., Cotor) <br /> CAL. License NO. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Ga!-„Weights &Measures No. <br /> Equipment Parking-Add(es9 A ---- <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> t No. of Vehicles Stored <br /> No. of Chemidal Toilets-Stored- y - I �• ; <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.0ti E: m <br /> No' <br /> R.S. or R.C.E. Name <br /> Test Location--t;: "M Test Date/Time <br /> 4. ❑-,SANITATIQNPERMIT- <br /> Job <br /> PERMITJob Address/Location may_ <br /> Address <br /> Owner ❑ CESSPOOL ❑ILEACHING FIELD ❑ SEEPAGE PIT ❑`PACKAGE�LANT• (' <br /> ❑ SEPTIC TANK #. 13OTHER � � Ay PERMANENT 11 TEMPORARY ❑1NEW 1:1 REPAIR ►+ <br /> 5. CIL CHEMICAL TOILETS For.July 1, -June 30, 19 F <br /> ' Disposal Site <br /> Type'Construction: � �'` �-'' '�' # p - <br /> _ r r' s ?Equipment• Stora e//CleaL�g+ocation(s} <br /> No. of Units` ” 1 ' 9. t W <br /> For 1I u1y 1, -June 3l,_196. ❑ PACKAGE TREATMENT PLANT 'rT ' t <br /> Where certified <br /> EE ' <br /> i Operator Name <br /> Plant Location <br /> No. Units Servedi " <br /> Plant Capacity j ( r <br /> 7. ❑ LAUNDRY FoO,Iuly 1, -June 30, 19 <br /> ❑ More Than 1,000 Sq. Ft. r - 1 '�" <br /> ' SIZE: ❑ Less Than 1,000 Sq. Ft-, � �, E� � � p� 4-7 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done m accordance with San Joaquin County <br /> ordinances,;state laws, and rules and regulations of the San Joaquin Local Health District. i C <br /> APPLICANT'S SIGNATURE X <br /> y i <br /> t i FOR DEPARTMENT USE ONLY <br /> > A I E <br /> Fee Is Due: ❑ ANNUEl❑ PER UNITI ❑ PER SITE ❑ EACH Jauary 1 &Received By January 31 0 July i &Received By July 31 <br /> Sn <br /> — REMIT <br /> # 4, BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE } <br /> LESS } <br /> PRORATION <br /> PLUS <br /> ----PENAL-TY.. — <br /> r <br /> ` <br /> } <br /> OTHER • ' . -�i �f�� _ . <br /> I <br /> s--OTHER <br /> Received 6y Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952U1 <br />