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Appiications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The App Ica Ion. <br /> APPLICATION <br /> (For Non-Transfe'iable,'Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE` J <br /> Application is h5fty mad 'o arlgn business in the jurisdictional area of the San Joaquin Local Health Distrl t : <br /> A d ess <br /> r Business Name (DBA) ' <br /> Address , <br /> zz Owner <br /> 2 Firm Partners, Addresses and Telephone Numbers r r <br /> aBusiness Telephone,No. � : Emergency Telephone No. <br /> .J Contractor Licence No. <br /> Applicants Name (Print) v -- Title Date <br /> Please check Applicable Category(t-7). nd Fill in the Required Information,t, P,I.: }, 'zt ,• £a x , . t-. <br /> i. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> Far 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 /> i 2. ❑ PUMPER YARD. - <br /> For July 1, June 30;`19No. of Vehicles Stored _ _No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST- <br /> R.S.or R.C.E. Name R.S.or R.C=E. No. <br /> Test L cation <br /> Test Date/Time F <br /> I 4. SANITATION PERMIT <br /> J Address/ ation _ <br /> Ow er /I Addr"SEEPAGE <br /> _ <br /> SEPTIC TANK ❑ CESSPOOL- LEACHING FIELDIT PACKAGE PLANT <br /> PERMANENT El -TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> CO CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction -- Disposal Site <br /> I t Equipment Storage/Cleaning Locations) <br /> No. 01 Units � <br /> 6. 11PACKAGE TREATMENT PLANT For July 1, -June 30;,19 Q <br /> Where Certified. <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 16- <br /> I <br /> 0, 19 - y: <br /> ❑ Less Than 1 000 S . Ft., ❑ More Than 1,000 Sq. Ft. <br /> SIZE: q � _ <br /> ❑ DRY CLEANING,Cherriicals Used/Amouht/MO. <br /> lfome ownerorffcensed agent'ssignature certMesthe following:1 Pert'sfy that in the performance el the work for which ih is permit is issued,10 at]not employ any person <br /> in such manner as to become subject to workman's Compensatil:,)laws of California.' <br /> Contractor's hiring or subcontracting 1 signature eeraiies the folknving. "I certify that in Tllc:performance n;the work far which this permit is issued,I shaft <br /> enaploy-persons subject to worktnan's compensation laws of California." ° <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 ane r gulatio*s ot'the San J aquin alth District. <br /> - r <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 ❑ Juiy i &ReceivedREMITuly 31 <br /> P. <br /> i EXPLANATION BILLING ` _ REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE <br /> I DATE DATE REMITTED AMOUNT <br /> FEE ; <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> OTHER <br /> 1 Received by Date Receipt No. Permit No. ' I uanc Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> '1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ' <br /> . w•r <br />