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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSign TheAppucanon <br /> APPLICATION <br /> (For Non-Transferable,Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby ma0eto carry on business in_the jurisdictional area of the�n Joaquin Local ealth Distric <br /> 'ti ! Address ` f <br /> OF Business Name (DBA) _ - <br /> r e i Address <br /> cn <br /> a Owner . — - � , <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No.-Contractor Licence No. c _ �� Y �/��- - Date <br /> Applicants Name (Print) P .• i'r� r 1 Title 5 <br /> Please check Applicable Category ( -71 and Fill in the Required(Informatkon <br /> ) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O <br /> For July 1, . June 30,19 Disposal Sites <br /> Description(Make/Yr., Color) °* CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address , <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name _. .. w ' <br /> Test Location Test Date/Time <br /> 4. .® SANITATION PERMITr t <br /> Job Address/Location 's <br /> Owner f .' Address _ <br /> 13 SEPTIC TANK ❑ CESSPOOL M�LEACHING FIELD � SEEPAGE PIT ❑ PAtSKAGE PLANTi' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER t,fyAF_-r <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 3o, 19 ) � �� 461 !'6 d` `��I 49 !� � <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) k <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,- June 30, 19 <br /> Operator Name Where Certifled <br /> Plant Location 3 <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft-, El More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ,y „ <br /> Homeowner orlicensedagent's signattrrecertifiesttmfe0owr±tg:1certif thatiniheparformanceofthe work,for which Mispermit isIssued,Istiallnot employ any person <br /> in such marm8r as to become subject to workmnrs s cow.pensatlr:naY'o#'r,i- ' f <br /> Contractor's hiring or sub-eontrac.Vnq.sfnilaturn the perfor^a;see e`::ta vaork tpr whtctt this permit is issued,I shall <br /> employ persons subject to werkmarfs uompansarivn laws u;Luiiiu;iii.. Y <br /> E I hereby certify that I have prepared this application ag th ork F be done in accordance with San Joaquin County <br /> ordinances, state laws, and ruleS and regulations of the/ ui o Healh District. . <br /> APPLICANT'S SIGNATURE'X <br /> FOR DEPARTM T USE ONLY. <br /> l Fee Is Due: ❑ ANNUALLY 101 UNIT, ❑ PER SITE ❑ EACH ❑ January 1 &Received ByJanuary31 ❑ July 1 &Receiv REMITd By uly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE W ''-EXPLANATIONDATE. DATE- REMITTED AMOUNT <br /> FEE <br /> LESS + <br /> PRORATION <br /> ! t�PLUS - <br /> PENALTY v <br /> OTHER '( <br /> OTHER <br /> 73 -- OCA <br /> } Issua ce Date. Mailed Delivered <br /> Received by - Date Receipt No, Permit No. <br /> -APPLICANT—RETURN ALL COPIES t0: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 <br />