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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> - <br /> (For.N on-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> } LIQUID WASTE <br /> Application' erebrryy made aon siness in he jurisdictional area of the San oaquin Local Health Distri <br /> FBusiness Na (DBA) Address 0F -74 7j <br /> e Owner Address -�+-��— i <br /> Firm Partners, Addresses and Tel honeu bers <br /> CL Business Telephone No. Emergency Telephone No. s <br /> Contractor Licence No. j <br /> Applicants Name(Print) Title —.� - Date <br /> Please check Applicable Category (1-7) and Fill in the Re ired Information T <br /> 1- ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) } I <br /> For July 1, June 30, 19 - Disposal Sites <br /> h Description(Make/Yr., Color•) <br /> c - <br /> Serial No. CAL. License No. + - CAt__. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address ' <br /> 2. ❑ PUMPER YARD M <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored r <br /> 3. ❑ PERCOLATION TEST 1 <br /> R.S. or R.C.E. Name R.S-or R.C.E. No. <br /> Testme <br /> .,Loocation Test Date/Tii <br /> 4. Ill SANITATION-PERMIT -� a <br /> Job Address/L ation <br /> 117 <br /> Owner Address .� <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 5 PAGE PIT ❑ PACKAGE PLANT r f <br /> E] PERMANENT ❑ TEMPORARY 13NEW REPAIR x❑ OTHER <br /> 5- ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site y ' <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 > <br /> Operator Name Where',Certified <br /> Plant Location = �' <br /> Plant Capacity ` x Y" �- No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June X-19 <br /> Wi <br /> SIZE ❑ Less Than 1,000 Sq. Ft-, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals-Used/Amount/Moi <br /> f4omeownerorlicernsedagent's signature cerrlfaiifoliti 1 certify that In the performance of the work for which this permit Is issued,I shall not employ any persi <br /> in such man"sr as to beoomo subject.to workmaa i=-t;ompensatinn laws of California.' <br /> Contractor's hiring or rwb-ao#lfrncting asirinature corWies the following: "Iter rfy that in the performance of the work for wh:ch this permit is issued,l shall <br /> employ persons subject to weriurGi s ew,rpensado;:laws of Cali;oiaia. <br /> 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 rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT - ❑ PER SITE '`❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> RASE " ..EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT l <br /> FEE LESS <br /> 1 PRORATION <br /> PLUS <br /> i4. PENALTY <br /> OTHER a <br /> OTHER -� <br /> 3 <br /> -73 <br /> Received by Date Receipt No. Permit No. IssuAnce Dale Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - -1661 E.HAZELTON AVE.,P.O.Box'2009 STOCKTON,CA 95201 .I <br />