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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. _ <br /> 1�. APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGz <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made tp4rry on business in the jurisdictional area of the San Joaquin L cal Health District <br /> rn Business Name (DBA) �r�o r c�S r� ►4 k�< ( Address1z. <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �l 4 -/ Z 4 �' Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title 1 Date Q�� <br /> Please check Applicable Category(1-7)and Fill in thi 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. o heroical Toilets Stored <br /> 3./ ERCOLATION TEST <br /> R.S. or R.C.E. Name R,S.or R.C.E.No. <br /> Test Location Test Date/Time 7_z> -45- <br /> 4. ❑ SANITATION PERMIT gr C44,4Z— <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT O TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 /> �Iemserw+srerNeettsadsgetrt'sdgtletursew-r'Nesthet- <br /> *11ow&*:"I certifY that 1"the Perfortnanceof the woritfor wHch this permit is Issued,I shall not employ any person <br /> in such manner as to bmme subject to worklaan's compensation taws of Califol044. <br /> Coetractor's hiring or sub-contratting smote aentfies the f lliowiay; "I certify that 1n the performance of the work for which this permit is issued,I shall <br /> employ persons sutt)eot to workman s ewnpeasation laws of Calltorttia." <br /> I hereby certify that I have prepared this a lica I an that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and les and reg a ons f he an 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 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 0 DATE - DATEREMITTED AMOUNT <br /> FEE ©C) Z r'Wt S ig is lQ <br /> LESS <br /> PRORATION <br /> PLUS ✓� <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date 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 />