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Y dproperty <br /> Applications Will Be Processed When SubAPPLICATION <br /> SEPTAGE <br /> (For Non-Transterabie,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH <br /> PERMIT <br /> LIQUID <br /> Joaquin Local Health District <br /> mai a to carry on business in the jurisdictional area of the San <br /> Application is hereby Address <br /> F Business Name (DBA) i .Address ` <br /> aOwner Tele hone No. <br /> Firm Partners, Addresses and Telephones umbers Emergency - P <br /> a Business Telephone No. <br /> itle pate <br /> - <br /> Contractor Licence No. T =T <br /> Applicants Name (Print) wired lntorrnaiion w <br /> Please check Applicable Category (1-7)and Fill in the Req \. <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (pOpo EACH <br /> Sites VEHICLE) <br /> For July 1.,�.June 30, 19 <br /> Description(Make/Yr., Color) i CAL, License No. CAL.License Renewal No. <br /> _ yt _ Gl Weights &Measures No.Serial a; c <br /> f <br /> Capacity , <br /> - ; <br /> Equipment Parking Address - L <br /> 2: ❑,pUMPER YARD I s <br /> For July 1,_ June 30, 19 <br /> No. of.,VehicIesStorbd t 4. <br /> No. of Chemical Toilets Stared � <br /> '1 M F ° '•ti <br /> 3, ❑ PERCOLATION TEST f•� R.S. or R.C.E. No.�..� r� • <br /> R.S. or R.C.E.Name Test Date/Time <br /> Test.Location k ` <br /> ,4. SANITATION PERMIT <br /> Job Address/ cation rJ t Address 13 PACKAGE PLANT <br /> Owner ❑ CESSPOOL -P(LEACHING FIELD SEEPAGE PIT 13 OTHER <br /> , <br /> ❑;SEPTIC7ANK 13 NEW REPAIR z <br /> ❑ PERMANENT'' ❑ TEMPORARY <br /> ❑ CHEMICAL t _ ; �---...•". <br /> CAL TOILETS. For July June 30, 19 <br /> 5 #1,- Disposal Site <br /> Type Construction t ' <br /> Equipment Storage/Cleaning Locations) 1 <br /> No. of Units5 . <br /> ElPACKAGE TREATMENT PLANT For July 1. June 30, 19 Where Certified <br /> Operator Name <br /> � r <br /> Plant Location ? No- Units Served---( l <br /> Plant Capacity <br /> 7, 13LAUNDRY For July 1, -June 30, 19 <br /> ❑ an More Th1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., e <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. Ji <br /> r' <br /> application a that the work will be done in accordance with San Joaquin County <br /> I hereby certify that 1 have prepared this app i <br /> ordinances, state laws, and rules and regulations of a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE,X ' <br /> FOR DEPARTMENT USE ONLY <br /> _ i ❑ July 1 &Received By July 31 <br /> ❑ Sanuary 1 &Received BY January 31 REMIT <br /> Fee IS Due: ❑ ANNUALLY <br /> PER UNIT PER SITE ❑ EACH $ AMOUNT DUE CHECKED - <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANATION DATE + DATE <br /> FEE � r - <br /> 4 y <br /> LESS <br /> PRORATION <br /> F i i <br /> PLUS <br /> PENALTY <br /> p, 2 �,• s. <br /> OTHER <br /> OTHER, <br /> 7 ,��5.,1- Issuance Date Mailed <br /> De;ivered <br /> Permit No. - CA 85201 <br /> ,i•'F"C.eceivby ed <br /> by'�J"•`� Date " +Receipt No. <br /> _ R <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 5691 E.HAyELTON AYE.,go.Box 2009 STOCKTON, <br />