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Applications Will Be Processed When Submitted Properly Completed. BeSureTo sign <br /> APPLICATION <br /> (For Non-Transierable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> to At <br /> Applicat is hereby ode to car on bus'.e s in t jurisdictional area of the S�I�txloaqual� lstric <br /> yBus+nes ame (DBA) it Address—�(_�—� -� <br /> Address <br /> i Owner <br /> a <br /> Firm Partners, Addresses and Telephone / mbers Emergency Telephone No. <br /> ll <br /> CL Business Telephone No. i' <br /> a � <br /> Contractor Licence No. Date . <br /> Title <br /> Applicants Name,(Print49or Please check Applicabl (1-7}and Fill in the equired Intormaiion 1 <br /> 1. ❑ PUMPER VEHICLE-PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal Sites <br /> For J U I y 1, June 30,'19 <br /> Descriptjon1'(Make/1,6:1 Color)"4 CAL. License Renewal No. <br /> Serial No. -- � CAL. License No. I <br /> _ <br /> Gal.,Weights & Measures No, <br /> Capacity <br /> Equipment Parking Address - <br /> 2.'❑ .P.UMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored t' <br /> No. of Chemical Toilets Stored { <br /> 3, ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S.or R.C:E. Name j <br /> cy Test Date/Time <br /> Test 1-090ion - <br /> p 4. SANITATION PERMIT <br /> Job Addre Location7 �!t <br /> Address %j <br /> Owner ❑ PACKAGE PLANT q} <br /> 101 SEPTI TAN ❑ CESSPOOL 13 LEACHING FIELD � SEEPAGE PIT (f <br /> RPERMANENT ❑ TEMPORARY ❑ NEW RFtEPAIR ❑ OTHER <br /> 5. 11 CHEMICAL TOILETS'-For-July 1, -June 30,19 +(� <br /> Type-Construction Disposal Site <br /> .No of Units Equipment Storage/Cleaning Location(s) <br /> r6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> , } <br /> .- Where Certified <br /> OperatorName <br /> Plant Location _ <br /> Plant Capacity x ,.. No. Units Served <br /> 7, ❑ LAUNDRY For July 1;=Jul4e 30, 19 <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than.1,000 Sq. Ft. <br /> l ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 146mo owner or licensed agent's alpnmuen certifies the following!1 certlfy that In t1te pesTotmance of the work for wfdch lMs permit is Issued,I shall not employ any person <br /> in such manner as to become sabject to vmrkmarl's compensiftgo laws 01 California." <br /> Contrrcters hlrl or auD cont!ncte�sp ��?�atuKe cortHins the !opawin9: "t certtf,'hat in the performance of tiie lark for vrhich t is�srmit is isstled,l shall <br /> k cmftlay persons subject w,;mfkalalt s comp.,,tsation lays et r,�.lilornia,' <br /> I hereby certify that I Clave prepared this application and that the work will be done in accordance with San Joaquin County <br /> k ordinances, state laws, d rules and re ulat' ns of the San Joaquin Local Health District" <br /> APPLICANT'S SIGNATURE X <br /> kL <br /> l FOR DEPARTMENT USE ONLY <br /> R UNIT ❑ PER SITE ❑ EACH Cl January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY E3 PER REMIT <br /> i BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> ! FEE -.,,,�• �, - <br /> LESS- <br /> PRORATION <br /> k # <br /> PLUS w ' <br /> PENALTY <br /> i OTHER <br /> OTHER <br /> } <br /> Date Receipt No, Permit No. Is uance ate Mailed Delivered <br /> Received by 1601.E.HAZELTON AVE.,P.O.SON 2009 STOCKTON,CA 95201 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES �" <br />