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€ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> f (For Non-Transierable;Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i reby made to o busi ss in the jurisdictional area of the San Joaquin Local alth District <br /> n Business Name(DBA) ' <br /> ' -Address <br /> i Owner. Address <br /> Firm Partners, Addresses and Telephone Num ers u 4 <br /> I a Business Telephone No < Emergency Telephone No. <br /> .J Contractor Licence No. r y _ <br /> Applicants Name (Print) 1 Date <br /> a Title <br /> Please check Applicable Category(1-7) and Fill In the Required Information o <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOA EACH VEHICLE) Q 5 <br /> For July 1, .. June 30,19 M- Disposal Sites - --- a <br /> Description(Make/Yr., Color) `` <br /> I 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 /> 4 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored _ <br /> j 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. PtSANITATION PERMIT 4 1 <br /> 'Job Address/Location— a _ t< <br /> Owner ��`� � -- Address <br /> -SEPTIC TANK CESSPOOL 69-LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> ❑ PERMANENT s ❑ TEMPORARY iJ.N6V ❑ REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> i Type Construction r Disposal Site ' <br /> No. of Units ° I Equipment Storage/Cleaning Location($) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 J <br /> Operator Name ;- I Where'Certified, <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. P LAUNDRY..For July 1, -tune 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owneror N*nsed egent'ss;gnature certifiesthe following:"I certaiiyy that in the performance of thawark for which this permit is issued,I sha€t not employ any Pers o n <br /> I in such manrter as to become subject to workman's compensation laws ofCafitarrtia�' - i ( - <br /> Contractor's [tiring or sub-contracting.signature certifies,the following: 1 Certify that in the performance of the work for which this pe:mlt,ls issued,I shall <br /> employ persons subject to workman's compensation laws of California" I ) t <br /> 1 j 1 ,. <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, an ul and r ulatio of the San Joaquin-Local Health Di rict. { <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 i &Received By July 31 <br /> t e . REMIT i <br /> " - <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE"" CHECKED <br /> ?: <br /> i DATE DATE REMITTED 1 `AMOUNT <br /> A. L o� F <br /> LESS <br /> PRORATION ° ! <br /> PLUS <br /> d I s J <br /> PENALTY .; <br /> OTHER <br /> OTHER r„-„+.}.•--,,,i, .- ate.`x.�r i�._ 4.4,-_ ......_ , ...ti,... <br /> Received by - Date - Receipt No. Permit No Issua ce Date I Mailed Delivered <br /> APPLICANT'-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES•' �- ” 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br /> - IJ <br />