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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT 5EPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaqui Local Health District <br /> OBusiness Name (DBA) Address d f CA�- <br /> aOwner �,�,�v L.L_�•—< Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. O�g <br /> .... <br /> 1 Contractor Licence No. <br /> Applicants Name (Print) 4 P.,L Title Date e,, An t <br /> Please check Applicable Category 1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) a <br /> For July 1, 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 /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 ",T <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 3 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT j � pgA i <br /> Job Address/Location Z 7/ O/ <br /> Owner Address r7 GC <br /> WS�TIC TANK ❑ CESSPOOL ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT . ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ' <br /> Type ConstructionDisposal Site <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 /> Plant Location <br /> Plant Capacity 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. I C <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> AA <br /> I hereby certify that I have prepared this application and.that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and re ulat, ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X — <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> -:$ILLING REMIT CE $ <br /> — BASE 'EXPLANATION - DATE D REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE "YJ� <br /> CIA <br /> LESS <br /> PRORATION Ff + <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER -' <br /> �6 lobft <br /> Received by Date Receipt No. Permit No. I ssuanife Dat6 Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />