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-Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icatio is hereby de t carry usi s 'n the jurisdictional area of tASaaqJ' ,calHealthJP4fArIct <br /> Busines a DBA) Address r <br /> z Owner Address <br /> Firm Partners, Addresses and Tele one Numbers - <br /> aBusiness Telephone No. Emergency Telephone No, <br /> Contractor Licence No. . <br /> iApplicants Name (Print) _ Title 3N Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information w>F s y i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June-30;-19 Disposal Sites— <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal:,Weights& Measures No. <br /> Equipment Parking.Address <br /> 2. ❑ PUMPER YARD <br /> i - <br /> For July 1, June 30-19, y <br /> No:ofyehicles Stored, <br /> No. of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST�' �� <br /> 'T^�. <br /> R.S.or R.C.E. Name "� �N "�� R.S. or R.C.E. No /r <br /> Test Location Test Date/Time j <br /> 4. Z-1ANITATION PERMIT <br /> Job Address/L cation <br /> Owner Address <br /> 13SEPTIC TANK E] C SSPOOL {ACHING FIELD G-SEEPAGE PIT PACKAGEPLA�NT �� <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 9'REPAIF ❑ OTHER r-, <br /> k 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 W <br /> Type Construction Disposal Site - �N <br /> No. of Units Equipment Storage/Cleaning Location(s) v <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 /%J, f� <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1; -June 30, 19 s. r „ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than I,000.Sq. Ft. '� I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. \� <br /> Home owner orjhmnsad Agent's signature rerti(ies the.f0{I* !jrvw 1cert!tV'hat lR thBilCrformanceof the work for which this permit is issutd,I.shall not emIshall <br /> in such manner as to become subject to v/orki ar.'�t:cmf±ertsatien I :c 4C�liforrF r' <br /> Contractor'a hiring cer suss-contracting signartme certfffe5 the toflo«ring:' 'I certify tCaj in the performance of the work for which this permit is issu <br /> employ persons subject to workman's compensation laws of California" Irk-wili <br /> 1 hereby certify that I have prepared this applicatio nd tha he be done n accordance with San Joaquin County <br /> ordinances, state laws, an nd re Iations an aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> S <br /> FOR DEPARTMENT,USE ONLY- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ Pb SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ - <br /> $ASE EXPLANATION T AMOUNT DUE CHECKED <br /> DATE DATE REMITTED - eAMOUNFEE LESSPRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. suanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />