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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION J <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icali4ap is hereby m e to ca ry on siness'n he ju 'sdictional area of theSS/n Joaq}�n Local Health District /r <br /> rn Busines ame (DBA _ Address��� /�/hr <br /> i Owne Address <br /> a <br /> Firm Partners, Addresses and Telephlene Nu yrs <br /> CL <br /> Business,Telephone No. lJ t. Emergency Telephone No. <br /> Contractor Licence No. -2- i � 7 <br /> Applicants Name (Print) -- Title F Date -26 Cis. <br /> Please check'Applicable Cat gory (1-7) and Fil m the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I' <br /> ` For July 1, `June 30,19 Disposal Sites _-- - — <br /> Description(Make/Yr., Color)'` r <br /> Serial No j CAL. License No. CAL. License Renewal No. '` 6 <br /> Capacity t'- =' 1' -* - Gal., Weights & Measures No. k <br /> Equipment Parking Address ' <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30,-19 ' <br />- i <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored N <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. \ . <br /> Test Location Test Date/Time , ' <br /> 4. SANITATION PERMITO Z- <br /> Job Addreg/Location ge �C�Yn <br /> Ow r Address;w 5.�, CPO <br /> SEPTIC-TAN K❑'CESSPOOL -- 'LEACHING-FIEL-D—®SEEPAGE-PIT ❑ P KAGE.PLANT <br /> , <br />` ePERMANENT ❑ TEMPORARY ❑ NEW ®'REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, June 30,'.19: <br /> fe4Type Construction - Disposal,Site <br /> No. of Units # Equipment Storage%Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19� <br /> Operator Name - ` k- (�- � � Where Certified yti <br />` Plant Location <br /> Plant Capacity No. Units Served j R <br /> 7. ❑ LAUNDRY For July 1,.-June 30, 19 t t : <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,~ ❑ More Than 1,000 Sq. Ft. t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. f <br /> Rome owner or licensed agent's signature certifies the following:"I certify that fn the performancbof the work f or which this permit is issued,I shall not emn lay any Pers^n <br /> in such mariner as to become subject=o workman's compensation laws of.Califorrif <br /> Contraclor's.t:irinQ or sub-contracting signature cerciiio, tha fallowing`"l cernfy1t zr%in+ie pw,'os mance Gi the work far which this permit is issued,I_shail <br /> employ persons subject to workman's compensation laws of Cahtorrlia." <br /> r I hereby certify that I'have prepared this application and that the wo h will be done in accordance with San Joaquin County <br /> ordinances,"state laws,tarid-rules and regApon,4 of the San JoaquirLocal Health District. <br /> APPLICANT'S SIGNATURE X JU <br /> FOR'DEPARTMENT USE ONLY <br />` Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH 61"January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE <br /> BASE EXPLANATION BILLING --REMITTANCE, $� AMOUNT DUE CHECKED <br /> DATE DATE V REMITTE AMOUNT <br /> FEE - <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY + °' <br /> OTHER <br />= OTHER _ <br /> —Z19 <br /> Receivedby Date Receipt No. Fermi o. Issuance Date - Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - -1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />