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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 4 APPLICATION ' <br /> (For Non-Transferable, Revocable',and-Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic in�here�yy ma to c rry usine i he juri fictional area of the oaqu Local Health Distric <br /> yBusines ame (D8 /. Address <br /> a Owne Address_g5 <br /> Firm Partners, Addresses and Telephone' umbers R ' <br /> aBusiness,Telephone No. Emergency Telephone No. <br /> Contractor LicenceJo <br /> - <br /> L Applicanfs_Name{Print) Title Date <br /> Please check AppiicabwC ory (1-7) and Fill In the quired Informatlon r ` <br /> 1. ❑"PUMPERVEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> -For Duty 1: `—`- 'June,30, 19 - Disposal Sites <br /> Description(Make/Yr.,Color)`' <br /> SerialNo:' �. V CAL. License No CAL. License Renewal No. <br /> Capacity :. �' Gal., Weights &Measures No. <br /> Equipment arki'ng Address---t--k <br /> 2_0.PUMPER YARD 1 ) <br /> For July 1, - June`30, 19 <br /> No: ofTVeh cies Stored <br /> r <br /> .No. of Chemical Toilets Storedy <br /> 3. ❑'`PERCOLATION TEST' _ r I <br /> R.S. or.:R.C:E. Name.., 3 `t R.S. or R.C.E. No. <br /> Test Ldedtion T <br /> Test Date me c <br /> 4. SANITATION PERMIT�,.�--r. <br /> Job Addr ss/Locat o P - <br /> Owner Address <br /> �,� <br /> �O�'SSEPTI�ANK ❑ CE POOL BLEACH NG'FIELD' ❑k'8tEPAGE.PIT r❑-PACKAGE PLANT r( r r�— <br /> � I✓ERMANENT ❑ TEMPORARY D!NEW C1 REPAIR �ta-r <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 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 11-9 �. <br /> Operator Name a " <br /> Where Certified 1 <br /> Plant Location .,,. <br /> Plant Capacity R , No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> a SIZE: ❑ Less Than 1,000 Sq. Ft., 13 More Than 1,000 Sq. Ft.l <br /> ❑ DRY CLEANING,.Chemicals Used/Amount/Mo. F <br /> Home wrrerorlicensedagent'salgriatur�certrfiesthefollowing:"I certify that In the performance of the work for which this permit is issued,Ishall natom ployany person x <br /> in such manner as to become subject to 06rkman's compensation taws of CaMorn;a." , ^. _z= <br /> Contrsc_tor'si hiring or sub-contracting tsigirature certifies the. following., "I certify that If,,the perform3Aca oT hC;vL�!'k,iof•'Nhich this p&rmftds'�isSUed�." <br /> employ personssubject to workman's coi �einsa.tb7 laws a,Caii,ourda:' %? // �` �y� ��• *�' <br /> I hereby.certify that lk have prepare <br /> this plication and that the work will be done in accordance with San JoagCpunty <br /> sordjnahces;`state 1aYvs;and rules and-r ula 'Ons of,the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE)(:, ^` y60, <br /> S ' <br /> ''-FOR DEPARTMENT USE ONLY. <br /> Feeds Due:.❑ ANNUALLY ❑ PER UNIT' ❑ PER SITE❑ EACH ❑ January 1 &Received By January 31 ❑ July 1`&'Received By,Juiy 31 <br /> cif BILLING ^ REMITTANCE $ REMIT - <br /> BASE EXPLANATION AMOUNT-DUE CHECKED. _ <br /> a DATE DATE REMITTED y^..J AMOUNT <br /> { <br /> FEE <br /> 4�- <br /> 4..LESS r ry r -e" <br /> , <br /> PRORATION <br /> f <br /> PLUS rs t j <br /> 'PENALTY' <br /> OTHER A '} <br /> � f <br /> -OTHER <br /> Received by Date.y Receipt No: Permit , a. �!$S ante ate Mailed <br /> eliver,ed <br /> D <br /> APPLICANT—RETURN,ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1 4t*E:,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> - <br />