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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) SEPTAG7 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i eby made t c ry us' s in the jurisdictional area of the San Joaquin Local H ist�riictt <br /> rn Business Nam ( BA) >- Address <br /> aOwner Address_5C ;70W ig <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. L �G< Emergency Telephone No. <br /> Jr <br /> Contractor Licence No. <br /> Applicants Name (Print) Title ' '' Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) '1 <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. ❑ SANITATION PERMIT <br /> Job Addre s/Loc/atiZ/V 0117 v <br /> Owner ,[r;�, ���,�r� '�AyIG� Address QZD1eI ' <br /> AW-SEPTIC TANK ❑ CESSPO&L7 ALLEACHING FIELD Q:!$EEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY XNEW ❑ REPAIR 11 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 .74 <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 /> Nome owner or licensedagenYssignaturecertlfksthefoflosving:"tcect}fythatinthepertormallctOftheMorkforwhfctlthispermitistssu shall no <br /> in such manner as to become subject to workman's compensation laws of Ca(i!orfia:' <br /> Contractor's hiring or sub-contracting signature certifies the folloMng: "I certify Mat in the performance of the work for which this p6cDtit is issued,I shall <br /> employ persons subject to workman's compensation laws of California. <br /> I hereby certify that I have pre re this piic and-that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, andr s an re do of a Joaq ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT LAE 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE rj­ (4 S Q <br /> LESS <br /> PRORATION \ i1w <br /> PLUS <br /> PENALTY,_ <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issue e D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZE AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />