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=z <br /> ApplicationsWill 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 SEPT,AGE <br /> LIQUID WASTE <br /> Applicati is hereby m e to carry usiness in the jurisdictional area of the San Joaquin L cal He th Distr' r <br /> FBusines a @ (DBA) �" P Address �( <br /> a Owner Address <br /> a Firm Partners, Addresses and eIephone Numbers <br /> a Business Telephone No. — b t ` <br /> Emergency Telephone No. <br /> Contractor Licence No. <br /> a <br /> Applicants Name (Print) W Title —le� <br /> P Date_ 4� 7—�z <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q 1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc ase Renewal No._ <br /> Capacity Gal., Weights & Measures No.'­ <br /> Equipment Parking Address _ ,l <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.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time } <br /> 4. ❑ SANITATION PERMIT <br /> Job Add r /LO catian `' ev,qg,eie /C� s <br /> Owner Address <br /> C} EPTiC TAN ❑ CESSPOOL WLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER f- <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site �C► <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 , <br /> t Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 J <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 1 <br /> ordinances, state laws, dr es and regulations of th ag Joaquin Local Health District. <br /> 1 ' - <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 &Receiyed By.July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE07 <br /> LESS r- ' <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> T <br /> Received by D to Receipt No - Permit No. a e Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH'PERMIT/SERVICES 1601 E. LTON AVE:,P.O.Box 2009 .STOCKTON,CA 95201 J <br />