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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheAppTICanon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I LIQUID WASTE <br /> Applicati is hereby made to carry on bus' s in the'urisdictional area of the an Jo uin Local Health DistrictIL <br /> N Busines ame (DBA) <br /> Address <br /> z Owner Address <br /> 4 <br /> M Firm Partners, Addresses and TfTelepho�e!umbers <br /> E Business Telephone No. �� Emergency Telephone No. <br /> i -i Contractor Licence No. <br /> �Applicants Name"(Print), <br /> Title Date f <br /> Please check/Cpplicable Ca ory (1-7) an�FFM �tRequlred Intormation <br /> I 1. Q,PUMPER-VEHICLEPERMIT REGISTRATION (FOR EACH VEHICLE) <br /> `— - Dis osal Sites <br /> F <br /> For July 1, June 30, 19 p <br /> Description(Make/Yr-.;Color) <br /> Serial,No. CAL. License No. CAL. License Renewal No. <br /> ti. <br /> Capacity "F'Gal.,Weights &Measures No. �f <br /> I Equipment Parking Address <br /> 2. ❑ PUMPER YARD- r <br /> For July 1,, June-30, 19 ; <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST- k <br /> I R.S. or R.C.E. Name. R.S. or R.C.E. No. <br /> f Test Loc ton " Test Date/Time <br /> 1--ad;.4. L4 SANITATION PERMIT <br /> Job Ad / ocation <br /> i }, Addres - <br /> Owner ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT <br /> IIfERMANENT ❑ TEMPORARY ❑ NEWPAIR S <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 W <br /> r �; Disposal Site 0 <br /> Type Construction ' _ - � `� <br /> No. of Units `� .+. Equipment Storage/Cleaning Location(s) <br /> t 6. ❑ PACKAGE TREATMENT PLANT '.For July 1, - June.30, 19 <br /> 3 Where Certified <br /> r Operator Name - <br /> Plant Location <br /> —No—units-Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Tl 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.' <br /> *mow eewner or licensed aWlt's a+mature cerofiee th.1isno,wing:1 cePtityy that In the pertormince of the work for whiC41111is pirmllt is issued,Ishan not elnpby a"Verm <br /> in such manner as to besome.subject to workman's compensation lams at cafitomia " <br /> fm+trecto�e e,Tr:nA`of+ h-eontratNaq Ngnsture cor%fitas--the-folla wk,p: I certify that in the';I&Wrmanca of the work for which this persalt is issued,t sfudt <br /> a"loy persons subject to-workman`s comtgaitsation laws of California." . <br /> `w <br /> I hereby certify that. I have prepared this application and that the work will be done in accordance-with San Joaquin County <br /> ordinances, state laws, a d rules and re uta 'ons of the San Joaquin Local Health District. <br /> F APPLICANT'S SIGNATURE X s <br /> FOR DEPARTMENT USE ONLY <br /> r . <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 C1 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ l AMOUNT DUE CHECKED 41 <br /> DATE DATE REMITTED AMOUNT �!V1 <br /> FEE l s� L <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receipt No, <br /> Permilt No. �I �n e ate Mailed Delivered <br /> Received by Date <br /> 1601 E.HAZELTON AYE.,P.O.Box 2009 STO ON,CA 95241 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ��y��4� pt <br />