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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 <br /> LIQUID WASTE <br /> Applicatiog hereb made to ca(ry on b sine In the jurisdictional area of the San Joaqui Local H alth District <br /> r usiness Name (DBA) +� M �.�i ���� Addre S a�At <br /> Owner � d A re S 1 3 P z <br /> Firm Partners, Addresses a elephone NumberaLlIkize <br /> Business Telephone No. —� Emergency Telephone No. <br /> Contractor Licence No. v <br /> L Applicants Name (Print) L -_ Title Date 5 <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 <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 <br /> No. of Vehicles Stored - <br /> Noo Chemical Toilets Stored <br /> 3. A PERCOLATION TEST M C /� <br /> R.S. or R.C.E. N e o - , v V <br /> Test Location mw�ZC �D• Z'soo"Vet- v6. <br /> v.tl Test te/Time 1 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 11 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 "pment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For 3ulyJ, -June 30, 19 <br /> Operator Name Where Certified _ <br /> Plant Location <br /> Plant Capacity No. Units Sery --_s1 <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 /> I hereby certify that I have prepared Jab <br /> plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and. les and ns of the San Joa n Local Health District. <br /> APPLICANT'S SIGNATURE X --- - - - - - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY Q PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> ASE EXPLANATION AMOUNT DUE CHECKED <br /> DAT DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS / <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by 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 95201 <br />