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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> 1 ,, (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> VXV ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is twreby made to rry on business iaWe jurilpi4ictional area of the San Joaquin L cal H ah D' trict <br /> HBusiness Name (DBA) ' ress ) <br /> �� A <br /> z Owner Address ti <br /> a <br /> nu Firm Partners, Addresses and Telephone Numbers <br /> m Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) 6 V S Title d ww�� Date - <br /> Please check Applicable Category(1-7)and Fil in the Required Information i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, LJune 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal 140 <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 Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESS OOL ❑ LEACHING FIELD ,❑�rSEEPAGE PIT .❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW wlREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site tr a/.2p/<�,, • s,✓ je 1 ao �q <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 /> onm owneror licensed agent's signature certifies the following-1 certify that in the performance of thework for which this permit is Issued,I shall not employ any person <br /> in such manner as to become subject to workman's compensation laws of cali+nrt's <br /> Contractor's hiring or sub-contracting signature certifies the 10110wing: I certify Ulat in the performance ci the work for which this permit is Issued.I shall <br /> employ persons subject to workman's compensation laws of California." <br /> I hereby certify that I have pr pi <br /> d this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and regulations of P9S Joaquin Local Health District. <br /> APPLICANT'S SIGNATUiE X <br /> \\ i <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 /> IT <br /> BILLING REMITTANCE $ REM <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 61 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance D Mailed Delivered <br /> Iff <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL <br /> T0 O.Box 2009 STOCKTON,CA 95201 <br />