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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 /> *' ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is her y ma o c b sin s In the jurisdictional area of the n o al alt ' trl <br /> ,,F Business Name (DBA) �- Address <br /> V. <br /> z OwnerAddress <br /> a <br /> L) Firm Partners, Addresses°and Tel ne u bei; <br /> aBusiness Telephone No. Emergency Telephone No. <br /> J Contractor Licence No. <br /> L Applicants Name (Print) lWL-- Title to r ! <br /> Please check Applicable Category (1-7)and Fill in the Required Information p' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July'i, 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. ❑ PERCOLATION TEST r <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PE MIrT <br /> Job Addr s Locati (� r <br /> R <br /> Owner r Address - <br /> ❑ SEPTIC TANK ❑ CESSPOOL: LEACHING FIELD � 'EEPAGE PIT-'-❑ PACKAGE PLANT <br /> 1:1 PERMANENT 1-1TEMPORARYA EW goVREPAIR ❑ OTHER <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 /� r ` <br /> Type Construction Disposal Site ; <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 r, <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 /> Honeewner ertiesnaedagent'c Signaturecerr,flQathefo#10"ing:"I C"riify that in#wpertcrmanceof the+wcrkfor which this permit is issued.I shall rirot employ any person <br /> in such manner As to become subject Irl workmen's CvmpeasatiG:i laws of California <br /> Contmotor's hiring or sub-contracting sianatura oarsfmf tate fol:vwing: ._t6rtify that fn the performance of the work for which this rierrr.it is issue's;I shall. <br /> employ persons subject to wofkrnan's"mperisatiwl taws of Caiitornia. <br /> ­!!hereby certify a ve prepa d this plication an at the work will be done in accordance with San Joaquin County <br /> ordinances;s s, s nd regula ions th S n Joaqu 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 DAT REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by i Datd Receipt No. C3 Permit No. Issuanceto Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON .,P.O.Box 2009 STOCKTON,CA 95201 <br />