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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, RevocabFe;and Suspendable) / SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> w Business N eBA} Address z%2 1;;7f'�. O,�p� dP. <br /> aOwner Address —� <br /> J Firm Partners, Addresses and Tele one Numbers �V <br /> cBusiness Telephone No. 7-- -7? a- Emergency Telephone No. <br /> Contractor Licence No. / /17 - <br /> LApplicants Name (Print) �.� Po% f / /j ��' Title 04aAlifE! ���- 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, 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 /> 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. WSANITATION PERMIT� <br /> Job Address/Locatio_Q ' <br /> O ner r Address Z <br /> SS T ❑ CESSPOOL l� LEACHING FIELD SEEPAGE PIT ❑`PACKAGE PLANT �J <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 « J <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 <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> }lomeownererlicensedagent's signatvrer.Artifiesthe following:"I certify that in the performance of the work for which this permit is issued,I shall not employ any person <br /> in such manner Pn to become s:,L;^ t to:: ,..... s:v.^p ns lic.rr Iatios of Ca€J0,7 a. <br /> Contrec , <r; cc fis:e fullcwing: "I certify ihct in the performa^ce of the work for which the permit is issued,I shall <br /> employc:, ,,.,_L,op ­a2,cii laws,.!Califorria." <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 rule nd regulations of th San Joa in Local Health District. <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 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BRSE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> ul AMOUNT <br /> FEE 1� Q <br /> LESS <br /> PRORATION i <br /> PLUS f PENALTY 5 , ff � <br /> pW ;4/r std I.FG <br /> OTHER 6dif 4;14 <br /> OTHER G� <br /> Received by jDate Receipt No. Permit No. Issuan Mailed Delivered <br /> APPLICANT--RETURN AiL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZEL T AVE.,P.O.Box 2009 STOCKTON,CA$5201 <br />