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/ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _ J i APPLICATION .—f <br /> if r Non-Transferable, Revocable,and Suspendab � SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE y <br /> Application is hereb made to carry on business in the j r s Ictional area of the San Joaquin Local Health District. <br /> y Business Name DBA) /4 41.- `� NJ/� rl Address <br /> z Owner ���Y /� Address— <br /> Firm Partners, Addresses and Telephone Numbers ' <br /> 9997 -7 <br /> CL <br /> Business Telephone No. -'sov —,Emergency Telephone.No. � <br /> Contractor Licence No.dc <br /> . . <br /> Applicants Name (Pant) �1E�F. ��� U� i� � Title � �� s Date <br /> . _ .. <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; - - June 30, 19 Disposal Sites - - <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal 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. F(PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. �S <br /> Test Location X72(0 /I/ VIcS' f - Test nate/Time NI <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT \ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER C" <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 1 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> -7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Nome wAmeror licensed o"rit's eignaturacertiff"aw fonov ing:"I cwti tfyyt"!in the pertofmance of the waTR for which this permit is issued,I shall not employ any person <br /> in such manner as to beeallte subject to worRmari s eatnpensation laws of California. <br /> COntraCtor'a hiring or sub-contracting signature certifies the follrsavirog:a"t coni;y that in the perturmance of the wurk far which this permit is issued,I shall <br /> employ persons subject to workman's compensation taws of CaWornla" <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, and rules a d regulat' ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> i. <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> .. _ REMIT <br /> EASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE J DATE IREMITTED. AMOUNT-+ <br /> FEE <br /> ' LESS <br /> PRORATION "". T .. <br /> PLUS ;. <br /> PENALTY - <br /> OTHER <br /> OTHER 41- -44 ,,A <br /> rte:_-•µ ,� <br /> Recei ed by Date Receipt No. Permit NO. Issuance Date Mailed Delivered <br /> "' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJ$ERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201- <br />