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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 51 PTAGE <br /> LIQUID WASTE <br /> Application is here m de tarry ons ' ess in the jurisdictional area of the San oaquin oval Health District��,� <br /> O Business Name (DBA) �� � Address e� ,�°7YP�.A <br /> i! <br /> z Owner — Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> 5.a Business Telephone No. Emergency Telephone No. <br /> � Contractor Licence No. <br /> LApplicants Name (Print) 4, Title Date ^on,d <br /> Please check Applicable Category (1-7)and Fill in the Required Information i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ! �l <br /> For July 1, June 30, 19 Disposal Sites V- <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> 5, y <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, ' <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 --"T' 67 <br /> Job Address/Location f p , <br /> if <br /> Owner ✓° Address 4.1-2116- 1� 149 <br /> PTIC TANK ❑ CESSPOOL �LtACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal 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 /> Cl— <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More'Than 1,000 Sq, Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. _ <br /> I 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 rulesand re afo 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 /> BILLING EMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY i <br /> OTHER , <br /> OTHEH <br /> Received by Date Receipt No. Permit No Issfiance Date r Mailed Delivered OO <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />