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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} SEPTAG}I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE _ W <br /> Applica ' n is heyreby de to carry n pus'ne s in the urisdictional.area of the S oaqul Local Health District, - _ �_.J f <br /> H Busines ame (DBA Address n --- <br /> - <br /> i Owne Address M <br /> Firm Partners, Addresses and Telep a Numbers <br /> J <br /> CL Business Telephone No, Emergency Telephone No. p� <br /> Contractor Licence No. <br /> L ApplicantslName (Pant) ­Title� M j Date i t <br /> Plea3e check Applicable egory (1-7}and Fill In the Required Information i�,ya ) <br /> { S;.:I.i� "i`." r L .}:.asp.Y. r.;. �;,,-x" F' y r [_" <br /> 1. ❑�PUMP_ER VEHICLE,PEAMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1•, �� June 30,`19" a—. - Disposal Sites �] <br /> Description(aa-kelYr.ZColor)- <br /> Serial No, �-GAL."License•No..-- - _CiNr License Renewal"f o.• <br /> Capacity �Gal.,-Weights & Measures Nod'` t �l <br /> Equipment Parking Address ' - <br /> 2. ❑ PUMPER YARD s `> +" ,. S.r •�; i <br /> For July 1, -June 30,-19. Y i <br /> No. of Vehicles Stored <br /> No_of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. ! <br /> Testi o ation Test Date/Time <br /> 4. SANITATION PERMIT # <br /> Job Addr s Lo alio t <br /> O r Addressr <br /> TIC TANK ❑ CESSPOOL ❑ LEACHING FIELD. ® KA <br /> 'SEEPAGE PIT ❑ `PACGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW WIREPAIR ❑ OTHER <br /> 5_ ❑ CHEMICAL TOILETS For July 1,.-June 30, 19 <br /> i <br /> Type Construction Disposal Site <br /> No, of Units Equipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> a' d <br /> Op erator Name . Where Certified <br /> Ptant Location 4 ' ` <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 r <br /> r tw t tp <br /> :SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq, Ft, "+-+�- <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ' - 1 <br /> Home owner or ticertsad agent's xignatura certifies the fottoyAng:1 certiIVVat ir>'the performance bf the work for which this permit is issued,I shallnot employ any person <br /> in such m?mler as to become:L,blect io w i kmar.'s;xrlmer?52tlt n laves of tlalitomi i" c !J 1 <br /> Contractor's hiring or sub-ron?mctinU Eign8tvro certlfio,, tttt; 'ailovvfng: 'l ce�iiy tha?in liie performance GI tti�,;ork fo_r which this permit is issued,[shall <br /> employ persons subject to rvorkman'�6: napensatiGn iaw5 Ut Calilornia" d i t rH 1,. ' <br /> I hereby certify-that I have prepared this application and-that the work will be_done in.accordancewrth'San Joaquin County <br /> ordinances, state laws, and les and re alio of the San Joaquin Local Health District <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY _ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ Jusy 1 8 Received By July 31 <br /> ' BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED _ � r <br /> AMOUNT <br /> e FEE. <br /> LESS <br /> PRORATION <br /> 3 PLUS t \ <br /> PENALTY :.' <br /> OTHER. <br /> OTHER <br /> w <br /> Received.by Date ;Receipt No. Permit No. I uane Date Mailed Delivered <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2099' STOCKTON,CA 95201 <br />