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Applications Will Be Processed When Submitted ProperlyCompleted BeSureTo Sign Irte Appncauon. <br /> APPLICATION <br /> t (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Ap-piicatior here y ade to CAFry q�n uslnegsiiinn the jurisdictional area of the San Joaquin Local He Dist' <br /> t <br /> , <br /> yBusiness Name D8A) � `_' 19ZIfd� """'` Address <br /> z Owner /rYl Address <br /> 1 Firm Partners, Addresses and elephone Nu hers <br /> I Business Telephone No. 2 g Emergency Telephone No. <br /> Contractor Licence No. <br /> 1 <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Rer;ewal 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 <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/ oc tion <br /> Owner 61 r X41 ` Address <br /> ,-SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 yF <br /> Type Construction Disposal Site 45:-i 14 '�" �—fo <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 <br /> Plant Location <br /> Plant Capacity No. Units Served r <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 /> Name owner orficensed agent's signature certifiesthefo'.lrnving:"1 certlfy that In the per!ormance of the work for which this permft Is issued,I shall not employ any person <br /> In such manner as to becDan s sahjeet;n,3vo r .: 4.......,..., + <br /> Can*recr' <br /> far Et++Diel,:" i s eJ.!shad <br /> 1715, � I......�,..a..,,s........ ...:........:,....::�,;;::s...._ .._...,..,.,_......,..... '' ",-.�...., ��..... ; <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 and regulations of the Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> i2 5 <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEEJ�, <br /> LESS y <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER l <br /> OTHER <br /> p 1,3 ,:1- 0 143 <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.Bo■2009 STOCKTON,CA 95201 <br />