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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 r � <br /> {. Appl icationds ere made t c rry on u ss in the jurisdictional area of the Joaqu' Local alth Distr" t r a <br /> F Business Name (D �—v ddress 00, <br /> z Owner Ar Address ` <br /> a <br /> aFirm Partners, Addresses and Telephones Numb <br /> a Business Telephone No. (�< Emergency Telephone No <br /> Contractor Licence No. —3- <br /> L Applicants Name (Print) �'�� Title - � Date. <br /> "R 1 <br /> Please check Applicable Category (1-7)and Fill in the Required Information 41 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19.. Disposal Sites. 1 <br /> Description(Make/Yr., Color) ! fff <br /> Serial No. _ CAL. License No. CAL. License Renewal No. CA <br /> Capacity Gal., Weights &Measures No. '" K <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 l <br /> No. of Vehicles Stored <br /> 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 Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Loco "on <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL" ❑ LEACHING FIELD A4EEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW - ❑ REPAIR F ❑ OTHER / _ -j <br /> 5. ❑ CHEMICAL TOILETS. For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) l;A <br /> 6. El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name - Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> w 7.�❑ LAUNDRY For July 1, -June 30, 19— <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Remserwlarortiarpeds •* MrklAavrllt�'f ttreifttke�artselOwwarkferwhichthis permit isissuetIShall naemptoyanyperson <br /> IR such mllttnet 3i5 to deet SI 3� ntaa's om'p* satletr#ar►:,+0 qu Ii0,•'a' f <br /> commm" .a or ae+ toftI ttr>s t;, in the per#prtaa�sce of the work far which this permit is issued,I Shall <br /> employ persons stte}ect to wo*maws compensation laws of Catilant"." <br /> I hereby certify that I have prepared this applica'on and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules a r gulation f the San,Jpquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> ,J <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & ceived By January 31 ❑ July 1 &Received By July 31 <br /> . REMIT ...... <br /> BASE EXPLANATION BILLING REMITTAN $ AMOUNT DUE CHECKED <br /> DATE DATE;V REMITTED AMOUNT <br /> FEE -� - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1 <br /> OTHER <br /> Received by Date Receipt No. Permit No. [ Is n e ate Mailed Delivered , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O.Bax 2009 STOCKTON,CA 95201 <br /> I <br />