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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION - '< . t- <br /> o (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> LIQUID WASTE ~" <br /> Application is hereby made to car on business„Lr the jurisdictional area of San eaquin Local Health District + <br /> Business Name (DBA) Address C� <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. Emergency Telephone No, <br /> Contractor Licence No. . Z <br /> a Applicants Name Print STA .�iM� <br /> � pp (Print) 11V'I�t�� _ 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. F CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures NO. r <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> r . <br /> For July 1, June 30, 19 4 <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.G.E. No. <br /> Tet cation A i Test Date/Time, ffF <br /> 4. SANITATION PERMIT r. <br /> Job Address/Location <br /> Owner1 Addre s <br /> SEPTIC TANK ❑ CESSPOOL )�EW <br /> EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARY ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 <br /> ,,,Plant Location j <br /> `Plant Capacity "' r No. Units Served t <br /> ❑ 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 /> H*M8 Lawrie 4D1'Mensed agOnt'S S191Mtt!re certHiesthe following:"I GertIfy that in the-performance of the W ori(f orwhirh this permit is Issued,I shall not employ any pe.rso n <br /> in sued manner as to bs~rome s.itliE�i tr,1'l�Fk;�1;;S+S compensatin^tay.- of wtiiafiiiA." - ; <br /> Contractor'-, hiring or srJk-roirtvAGting cig"itAn- ;-�- tVfieS 10w, xnttox'ir1): f cerfity lha:in lite iperf0::11ance rrf the work for which Ihis permit is issued,I shall <br /> employ per$Oi',S Sjbjec'to wotftY ZIfs 7(n 1:8iiCi l:`."s;4 of t0ali1,1Lni'd.' <br /> ` f"' <br /> I I hereby certify that hhave prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,•state laws, aggyyles and reg ationsofppSanJo n Lo I Health District. <br /> .'APPLICANT'S SIGNATURE X <br /> ok <br /> FOR DEPARTMENTUSEONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 i <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE AMOUNT �-+ ¢ <br /> FEE IAC 5,0 T 00 <br /> ! <br /> LESS <br /> PRORATION * ` <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ' 1 <br /> OTHER <br /> Received by Date , Receipt No. - -Permit No. Gg .Issuance D Mailed Delivered ( ' 1 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES. - - 1601 E.HAZELTON .,P.O.Bar 2009 STOCKTON,CA 95201 <br />