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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION ._ <br /> .W (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i rebmade to arty on but ss in a jylrisdi 'onal area of the Sa q Local fJ Ith District. p <br /> F Business Name (D C° ddress ti <br /> 4 Owner ddress <br /> Z <br /> Firm Partners, Addresses and T@Ie Numbers <br /> rrr. i <br /> a Business Telephone No. — � ���� - Emergency Telephone No.w Y <br /> Contractor Licence No. <br /> Applicants Name (Print) Title . ' Date <br /> Please check Applicable Category(1-7)and Fill.in the 146cluiredformation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites - <br /> Description(Make/Yr., Color) 1 <br /> Serial No. CAL. Livens No. + . "'a CAL. License Renewal'No. <br /> r <br /> ,,r I <br /> Capacity. ' Gal—Weights_& 10asurres No'. <br /> Equipment Parking Address I - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored 1 <br /> -t- / <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST �. <br /> R.S.ZR. Name t R.S. or R.C.E. No.TesTest Date/Time4. ATIO PERMIT <br /> Job Address/Lo ionO�W <br /> Own 1 r ` Address <br /> S IC TAIViK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT' k0 fPACI(AC3E PLANT* "'• :` �.; �� i <br /> PERMANENT, . ❑ TEMPORARY ❑ NEW ❑ REPAIR C1OTHER `j <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction` i ' Disposal Site <br /> No. of Units f ) ( Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name } Where Certified <br /> Plant Location t <br /> ( '. Units Served <br /> Plant Capacity t - - No{ I <br /> 7. ❑ LAUNDRY For July 1,j-June 30, 19r;-y %Z+ - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft:;"¢ ❑ More'Than 1,400 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Md F p �S, " <br /> #lame ownertxilCensed egenYssignature Certifiesthefdllawing:'t certify t31at in the perfol mance of the work fall which this permit Is issued,I shall not employ any person <br /> irl such manner as to become subject to worst n'S 66awrisatiorNaws of California:' I <br /> Contractors hiring or sub-contracting signature..certifies the following: "1 Cerlby that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workmans compensaftrl laws of California." i <br /> I hereby certify that I have preparedithis application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul d're ! t' n�- arT`doagDtn'L'ocal Health District. _ <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY' _ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 1 ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31_�-.r. [],,July 1 &Received By July 31 <br /> 46, r REMIT <br /> BASE EXPLANATION BILLING z REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE i„ DATE REMITTED r AMOUNT <br /> FEE ` - <br /> LESS <br /> PRORATION f "" Al <br /> PLUS <br /> PENALTY - <br /> , <br /> OTHER <br /> OTHER <br /> � r <br /> Received by Date - Receipt No Permit Ne. Issuance Date Mailed Delivered- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 ' <br /> II <br />