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NNnaanonsWillBeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION Pp <br /> F (For Non-Transferable, Revocable, and Suspendable) <br /> i ENVIRONMENTAL HEALTH PERMIT <br /> LIQUIB WASTE SEPTAGE <br /> Applicatio i ereby made to carry on ess in the jurisdictional area of the San Joaquin L cal Health District <br /> ,�Business N e Bq) 11 <br /> 1`- <br /> Owner Address <br /> Firm Partners, Addresses and Tee o Address <br /> 4 a Business Telephone No. Number <br /> Contractor Licence No. Emergency Telephone No. <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information Title Date <br /> 1- ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 <br /> Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. <br /> Capacity CAL. License No. <br /> Gal., Weights & Measures No. CAL' Lcc�lse Renewal 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 /> f <br /> R.S. or R.C.E. Name <br /> Test Location R.S. or R.C.E. No. <br /> 4. ❑ SANITATION PERMIT Test Date/Time <br /> Job Address/LocatiOD p � <br /> Owner <br /> Address <br /> ® SEPTIC TANK 13 CESSPOOL ❑ <br /> LEACHING FIELD 1:1 SEEPAGE PIT ❑ PACKAGE PLANT <br /> El PERMANENT ❑ TEMPORARY <br /> 5• ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ❑ REPAIR ❑ OTHER <br /> Type Construction t <br /> No. of Units Disposal Site � [ <br /> Equipment Storage/Cleaning Location(s) <br /> s• ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Plant Location Where Certified y <br /> Plant Capacity i <br /> 7. El LAUNDRY For July 1,.-June 1No. Units Served <br /> June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq, Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r <br /> 7 <br /> d <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, apolru es <br /> regulations of th an quin Lo f Health District. <br /> APPLICANT'S SIGNATURE X <br /> � f <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY .,❑ PER - <br /> tJNlT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 31. ❑ Jul 1 &- <br /> BASE BILLING - Y Received By Jvly 31 <br /> EXPLANATION REMITTANCE g REMf7 <br /> FEE <br /> DATE DATE REMITTED AMOUNT DUE CHECKED ate <br /> AMOUNT <br /> LESPRO <br /> � PRORATION <br /> PLUS <br /> ' PENALTY <br /> OTHER <br /> OTHER_ <br /> 6. <br /> Received 6y Date_ / P <br /> APPLICA T—RETURN ALL COPIES Tp: E Receipt,No, Permit No.- <br /> NVIRONMENTAL HEALTH PERMlTfSEAYlCES Issuance ate Mailed <br /> e Delivered <br /> }' - - 1601_E.HAZELTON AVE.,P.O.Box 2008 <br /> '��" � __ STOCKTON,CA 95201 <br />