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-Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the ju risd i ctional.area of the San_ Joaquin Local Health District <br /> ,,Business Nam 406A) f Address /y� <br /> 4 Owner /II Address 24 4 S-S'~ S. I'IJ-�� "c o <br /> Firm Partners, Addresses and Telephone Numbers 92 <br /> E. Business Telephone No, Emergency Telephone No. <br /> 1 Contractor•Licence No. <br /> L Applicants Name (Print) Title.dQA&IFAW #-0' Date <br /> Please check Applicable Category (1-7)and Fill in 1 e Required Information e. . <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 f <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 T <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Loc tion • <br /> Ow er Address 1� <br /> SEPTIC TANK ❑ CESSPOOL _ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER + <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site �T'1 <br /> No. of Units Equipment Storage/Cleaning Location(s) h <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 /> HOMO owner or licensed agent's signattire cerofrat,thr 4;2u awing;"I Cwti#)tl at inthe;ettormznCe of thezvor#cfor,rhi;h this�ermit is issue#.�shal!nc;employ any persc t <br /> in such manner as to hecorrle subject to x'orkntan's Compersaticsl#a>>ss of Ca;i;•r.;:i�;: <br /> Contractm's hiring or sub-contracting signreuro cArtif#e, i t ^n,;:owhlro : , r t,i{;'`„ `he perioT.^am?—cf thvt43rk tnr tv;1tC'?.:71. i' s is,'uatl,#shal, <br /> e,aploy persons subject 1,4 VJOr;,,,,na 1>u0t1�01,Sut:�I4 iawd of (1-- <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 gulations of the San Joaquin 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 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> s BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE ;REMITTED <br /> AMOUNT <br /> 6 <br /> FEE 4 <br /> LESS <br /> PRORATION' - <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Received by ate k - Receipt No. Permit No. - Issuance Date _ Mailed Delivered _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />