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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) / SEPTAGE <br /> 0 ENVIRONMENTAL HEALTH PERMIT d/ <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District. <br /> rn Business Qlame (DB ) - Address ' <br /> aOwner D Address d <br /> J Firm Partners, Addresses an��lephone Numbers t <br /> aBusiness Telephone No. - -T A6 Emergency Telephone No. <br /> Contractor Licence No. I 1 r Q 13 <br /> L Applicants Name(Print) —.'f Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) \ f <br /> Serial No. CAL. License No. - CAL. License Renewal No. Vv <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD r a <br /> For July 1, June 30, 19 <br /> -No.of Vehicles Stored f <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> a <br /> R.S. or R.C.E. Name �or R.C.E. No. = I <br /> r <br /> Test ocation e ate e r <br /> 4. SANITATION PERMIT � n �/f�-�� •—���� 1 � 5. �t �, � � ; <br /> Job Addre s/Location <br /> caner Addre s Qe> <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKA E PLANT f n <br /> PERMANENT —,,❑ TEMPORARY NEW REPAIR ❑ OTHER v5 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction 1 Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) t - �- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> _ I <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 } a <br /> SIZE: ❑ Less Than 1,000 Sq!Ft.,' ❑ More Than 1,000 Sq. Ft. t 3 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> HpmeownarorfEcertsedagc+rt'es3pnAtursee►risientlrefoltnwing:"Erertlfythatinthenertolmanceofthe werkforwhich tiiispermit€s Issued,IShall Mot employ anyperson i <br /> in such manner as to become subjed to woAlriarl's colitpensatian iaws of Ca ftfnid: certify that In the performance of the work tot width this permit is issued,i snail <br /> >Cp»trettGr'f hiAng nt auh-contracting 6,gnature certifisa she fotlowinq, .. <br /> employ persons su"t to workman's compensatieir laws of California" <br /> I <br /> I Hereby certify that I have prepared this application and that the work will'be dvrie in accordance with San Joaquin County I <br /> ordinances, state lawsra rus regulations of th San Joaquin Local Health District. `t <br /> iovAPPLICANT'S SIGNATURE.. <br /> r � <br /> n <br /> FOR DEPARTMENT USE C Y <br /> Fee IS Due: ❑ ANNUALLY ❑ PER-UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July I &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> • BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE- REMITTED AMOUNT <br /> FEE 6 ; <br /> LESS <br /> PRORATION ' ^•� ' <br /> PLUS <br /> PENALTY - - - <br /> OTHER .. . <br /> OTHER 'a <br /> Received by - - Date - Receipt No. Permit No. Issuance Date Mailed Delivered. <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />