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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APICATION <br /> (For Non-Transferrable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joa uin Local Health District <br /> y Business Name (DBA) AddressO_ <br /> aOwner =,( c2LrAddress s <br /> j Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print) �+ r 4 . Title �-f�- 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 �G <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 /> a <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT + 4 <br /> Job AdLocatio �D /e± <br /> Ownerdres / G r� /Nto4.Af , j <br /> Addres <br /> SEPTI�Ct�C ❑ CESSPOOL LEACHING FIELD 13 SEEPAGE PIT ❑ PACKAGE PLANT `h <br /> PERM T( ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. E] CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site — Q � <br /> No. of Units Equipment Storage/Cleaning Location(sj .d <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified C <br /> i <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 /> fiomeovlrrnerorlicensed a9 <br /> en!'ssiaht3`urP.rGr!;r�.c+,pe r»i, n, 4 �ti ' <br /> r,,'ti.ythatinthepertonnaTc afthe warp,forwNchthis Permit isissued, <br /> ;sha'I^otemp!byazyperscn <br /> inSuChma(tnerastJbecome <br /> C I1 a, <br /> Contractor's hiring c: GCrtify tha!in the perrarm,i<ce of tite work for which this permit is issued,I shall, <br /> employ persons subject tU:r0l h71d„b )i.i:e,5d+.�11 I:VI„Gi kali <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 rules and re tions the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> f <br /> . r <br /> f <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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - <br /> DATE . DATE REMITTED _ <br /> AMOUNT <br /> FEE i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY- + <br /> OTHER <br /> 41 <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered L <br /> APPLICANT—RETURN ALL COPIES TO:"'-#'ENVIRONMENTAL HEALTH PERMIT/SERVICES '1801 E.-HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 f <br /> 1# <br />