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Applications Will 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 SEPTAGE <br /> LIQUID WASTE <br /> Appl kation i herby made o carry on business in th ' risdictianal area of the San agUin Local Health DDi <br /> 'A Business Name BA). va- Address 76 <br /> i Owner Address .--..- <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No6— SS <br /> � (-� ' Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name {Print Titley Date <br /> Please check Applicable Category (1-7) and Fill in the Rilquired Information W <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1:7 June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Seria! No. CAL. License No. CAL. Lice lse Renewal No. <br /> CapacIty� ' -Gal.,Weights &Measures 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 PEST <br /> R.S. or R.C.E. Name R.S. or R.C:E. No. <br /> Test Location Test Date/Time } <br /> 4. ❑ SANITATION PERMIT , 1 <br /> Job Address/iLocation © 4 '�" <br /> Owner <br /> Address �r�fl <br /> ❑. S�PTIC TANK CESSPOOL ❑ LEACHING FIELD �EEPAGE PiT ❑ PA AGE PLANT <br /> l�'PERMANENT ❑ TEMPORARY ❑ NEW u ❑ REPAIR ❑ OTHER Qpj_ <br /> 5. © CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site {� <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19. <br /> Operator Name Where Certified <br /> Plant Location - - <br /> Plant Capacity _ N No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June <br />� E3 _30, 19 <br /> c SIZE: Less Than 1 000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. f <br />�❑ DRY CLEANING, Chemicals Used/Amount/Mo. - - <br /> arrtrerarNcansadsgawt's slgrtature aerefNelstltffa#Iwving:"I Corti ly tha+-intitaper/artnanCeot thtwork fOrwhiclt Mla perinit is issued,I shall not employ any perm» <br /> such mamter as to become sktbject to iirorkman s compensation laws of Ca iforola ' k <br /> Contractor's hirinti Or etb-eaenaetlrsb ftnature eer ifie's-the foltovrinp: "1 certify that in the performance of the work for which this permit is issued,I shalt <br /> employ persons subject to workman's Compensatlon laws of California." <br /> I hereby certify that I have prepared this applicat'on and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an les and regul on the San Joaquin Local Health District. <br /> r <br /> APPLICANT'S SIGNATURE X <br /> r <br /> o. <br /> FOR DEPARTMENT USE ONLY I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER.SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REWT I <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION - AMOUNT DUE CHECKED <br /> -DATE DATE .-. . w ;. REMITTED _ ... „ AMOUNT <br /> FEE � - <br /> LESS \ r <br /> PRORATION �l \ { <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - Date Receipt No. Permit No. Nskiance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,,P.O.Box 2009 I TOCKT N,CA 957,011 - <br />