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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSign TheAppucation. J <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable)�r- <br /> = <br /> ENVIRONMENTAL HEALTH PERMIT, SEPTAGE <br /> LIQUID WASTE � - <br /> Application i eby made to c rry on busi nes. n the'uns tion I area of the quin Local Health strict <br /> yBusiness Name (DB ` ss <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No. <br /> a Business Telephone No. <br /> s - <br /> -j Contractor Licence No. #" pate �� <br /> L Applicants Name.(Print) Title <br /> Please check Applicable Category(1-7)and Fill in the Required Information 'U; <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) + <br /> For July 1, <June`30, 19 Disposal Sites <br /> Description(Make/Yr.,fColor)1!: 1, <br /> k Der al No.T� �_� CAL. License No. <br /> CAL. License Renewal No. <br /> Capacity 4"> Gal.;Weights & Measures No. f_ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1 - .June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chem icai4Toilet,Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E.No. ,. <br /> Test L atation Test Date/Time <br /> 4. lf� SANITATION PERMIT I a <br /> Gl ✓ <br /> Job Address/ o atlon � f <br /> Owner �'y'� Address <br /> ❑ `SEPTIC TANK ❑ CESSPOOL LEACHING FIELD C�]' 11 PACKAGE PLANT cl) : <br /> ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR _. <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 C" <br /> ' Type Construction Disposal Site G. <br /> Equipment Stora Storage/Clean Location(s) - <br /> No. of Units9 9 s <br /> i 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 . <br /> Where,61 rtifidd w <br /> I Operator Name Y <br /> Plant Location <br /> I No, Units Served �. . <br /> Plant Capacity ..f <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 5q. Ft'. "' ry �O <br /> E] DRY CLEANING, Chemicals Used/Amount/Mo` -Z R.. <br /> L—ji <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County '1 <br /> ordinances, state laws, and rules and r tionstisttheSan Jo n L Balt Dct. <br /> k APPLICANT'S SIGNATURE X P f- <br /> FOR DEPARTMENT USE ONLY <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT -❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I DATE DATE REMITTED AMOUNT <br /> V <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Date - Receipt No, Permit No. <br /> Received by Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE., .O.Box 2009 .STOCKTON,CA 95201 <br />