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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 /> Applic • is hprel y made o carry q bu 'n s in th j 'sd' tional area of thV, oaq Local He Di trlct <br /> F Busines me (DBA) Address , E� -- <br /> i Own Address <br /> a <br /> Firm Partners, Addresses an Telephone Num rs <br /> aBusiness Telephone No. Emergency Telephone No. — <br /> Contractor Licence No. z-V—*- <br /> Cr <br /> L Applicants Name (Print) Title � Date � — 28: z <br /> Please check Applicable Ga ory(1-7)and Fill In th equired 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-r ❑ 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 SAtion Test Date/Time <br /> 4. lel NITATION PERMIT j2� <br /> Job Addres ocation �• <br /> Ow r Address <br /> ,_,AP (� <br /> TIC TANK ❑ SSPOOL LEACHING FIELD EPAGE PIT PACKAGE PLANT <br /> L7 PERMANENT ❑ TEMPORARY ❑ NEW O'REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site W <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 /> r <br /> Plant Location ' <br /> Plant Capacity No. Uni>s Served - <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowasro►fiwnssdagent'ssignaturecerNflesMefoflewi "fC. <br /> • rtg: c4#tfythatnthepertorman`cepithsrnorkiorwhichthispermhisissaed,tshallnotemptoyanyperson <br /> I*)such manner as to become subject•to workman's compensation tar's o1 C�ifarrra." <br /> CoP 101 Pero hiring or sera contracting f,,ai+;,,la certpCar, *hie {�1 ;certify that is the performance 0'the work for whick this permit is issued,I shall <br /> em;�lo� Persons subject to weri:man's com{tersai;a,t lah°5 of Cay v ' <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 ruIV and regulatio th an Joagl'in Local Health District. <br /> 1 <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE,.ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE 1 ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By_July31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> L DATE DATE REMITTED AMOUNT <br /> 3� 0 <br /> FEE �Y <br /> LESS <br /> PRORATION / <br /> PLUS <br /> PENALTY <br /> OTHER q— <br /> OTHER ✓���/ <br /> L3 yl� <br /> Received by Date Receipt No. Permit No. Issua ce Date Mailed Relive ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />