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Applications Will Be Processed When Submitted Properly Completed. BeSureTo 51gn ineAppucanon. <br /> APPLICATION <br /> ^� (For Nan-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT S�P7AGE <br /> LIQUID WASTE <br /> Appl is ition is hereby made to carry on business in the jurisdictional area of the S n Joa Lin L cal th Dis rict <br /> ,to/Business Name (DBA) Addres - <br /> Owner - Address <br /> 16 1 <br /> :0 Firm Partners, Address s d Tele hone u b rs� <br /> 5. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Date <br /> Applicants Name (Print)T�e <br /> Please check-Xp;o�cable Category (1-7)and Fill in the Required Information d <br /> 111 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites F <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 /> 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 /> J4. ,SANITATION PERMIT JJ�� <br /> ! Job Address/Location &Z-- 14 ss� - � Z,—IY4 Mto <br /> Owner G Address " <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ P KAGE PLANT --d1 <br /> ❑ PERMANENT 13 TEMPORARY 13 NEW REPAIR iD OTHER �3 .71< rddu)WC00dr <br /> 5a, ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site v, <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. --otb <br /> I here certify th ave prepay this cation and that the rk will be done in accordance with San Joaquin County <br /> ordinance la s, a r s and re atio the 6a 1 J uin L al Health District. <br /> APPLICANT'S SIGNATUREXZZL <br /> cvlpk,4�d -7 L6 80 <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 /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUF CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ` 1� <br /> LESS �1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by I Datd Receipt No. Permit No Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />