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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> APPLICATION i " PI,_ <br /> .. -, (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is herb made to car on business in the jurisdictional area of a San J aquin Local Health District <br /> y Business Name (DBA) ) 1Qt t� r?R.ISt - � C. Addresst'-d ���44S6 �SZ o <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a �Business Telephone No. — q! Q "C)Gd7 Emergency Telephone No. <br /> Contractor Licence No. Z- <br /> L Applicants Name (Print) Title Date <br /> 1 -� 1 <br /> Please check Applicable Category(1-7)and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) __J <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. w <br /> Test Location Test Date/TiTe <br /> 4. E SANITATION PERMIT <br /> Job Address/LocAatiion� I1Z. t-� _- <br /> Owner --F V_ -s�1 qle� 1 Address S�m� <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD XSEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 4NEW ❑ 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 /> Homeowner or licensed agent's signature certifies the following:'l cerMy that in the performance of the work for which this permit is issued,I shall noteirlploy any person <br /> in such manner as to become subject to werkmwfs compensation laws of Calitor ^. <br /> Contractor's hiring or sub-contracting signature certifies tbr, ratior.:nn c v'i' ",ha'in the performance of Ito work for which this permit is issued,t shall <br /> employ persons subject to workmaris comperrsation laws of Cufi(a,iiw" <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,ofd—r end regulat- ns of the Joaquin L Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER.';ITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING - REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE v{ ry <br /> x,. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issua ce 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 />