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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> p " ' 's APPLICATION <br /> 41 (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID wasrE y�� � � <br /> Application '6 h r b ade to carry on business in the jurisdictional area of the Joaquin ealth Di ict <br />#' X� <br /> Address NmH f <br /> i a Owner Address <br /> U <br /> Firm Pa I n rs, Addre� andTel�ep ne tubers r <br /> I Business Telephone No.. -�` .. 464� -� �, -- Emergency Telephone No. <br /> Contractor Licence No. <br /> �L Applicants Name (Print) - Title Date LI ' <br /> i <br /> Please check Applicabl tegory ( - -'and Fill in the Required Information <br /> 1. ❑ PUMPER VEHI&E 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. License Renewal No. ' <br /> Capacity Gal.,.Weights &Measures No. <br /> x <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ., r <br /> For July 1, June 30, 19 <br /> 'No. of Vehicles Stored <br /> No. of Chemical Toilets Stored 4. t <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Nan e t i R.S. or R.C.E. No. <br /> T t LoAtion ( Test Date/Time <br /> 4. .dANITATION PERMIT+Q <br /> SAddress/Location%' v I <br /> Address17t <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT. ' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER a 1 n- <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> r <br /> No. of Units Equipment Storage/Cleaning Location(s) i <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 <br /> 7. ❑ LAUNDRY . For'July 1, -June 30, 19 :, . <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000'Sq.-Ft. i <br /> ❑ DRY CLEANING,.Chemicals Used/Amount/Mo. f <br /> tlomea:vnera.li�s�sadagent'ssfgnzturacart�(:� thetolloLvintt:"Icerlifyihatinthep£riotm..rucofd)sworklor!'.'hichtl!ispormitisissued.lshallnotemployanype - <br /> in,. 'vo nlantie,as to beoon,.£Stab c'i-t:1'';,-k"la!1'� ".:tT'„�r15£ui0:^.iat <br /> Contractor's•hiring ar sub-centr0�tiny si�y#tu:e Cer,.iiie, trr''.OsiOs•Ma: "I GZriify thal in flip perforiltame-ol tim Work for LVNOI this permit is is ed,I Sha <br /> employ persans subject compensation la'N-of�aiifomia." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance With-San Joaquin Colfnty <br /> ordinances, state laws, and les and re u tions of the Sara Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT _ 0"_P1LR SITE x,;11 EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Rec ed By Jury 31 <br /> BILLING 'REMITTANCE `N Ta # REM1T <br /> BASE EXPLANATION DATE DATE IyREM REMITTED AMOUNT DUE CHECKED : .X <br /> 'AMOUNT <br /> FEELESS <br /> PRORATION <br /> PLUS I <br /> PENALTY <br /> OTHER ^ I <br /> _ I <br /> OTHER <br /> Received b Dale X Receipt No. Permit No. Issuance D642—,,). Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />