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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) 4,rPTAGE <br /> JJ 0 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is r %� ade to on. lrlws in the jurisdictional area of the San Joaquin Lealth Di t <br /> rn Business Nam ( BA) Address <br /> i Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L 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) <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 l <br /> No. of Vehicles Stored v <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 0!1— <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. 1 <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 6 i r 1 <br /> Job Address/Location 6/ <br /> OwnerAddress <br /> 11SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ 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 1r <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 5�t� <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. - <br /> Moms owner nrEicensec!agent's siJnntureo^rtifi st�efs9io2r y:"1C rti iia tftf^• 1,cLoft fJ, 1lieht(;i5permit iSiSSueu,i; allnOte^,ptayan rsr <br /> in such manner as to became subject to vior,unans..o nipwisatlou javls of Ca".rfa,nht <br /> Contractor's hiring or sub-contracting signature certifies the following: "'I certify that in the performance of the work for which this permit is issued,l s <br /> employ persons subject to workman's compensation laws of California." <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 r and reg latio f the San 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DTE 1AMITTED AMOUNT <br /> FEE <br /> LESS G, <br /> PRORATION i <br /> PLUS \� <br /> PENALTY <br /> OTHER 1 <br /> OTHER <br /> � 3 - I11c I� <br /> Received by Date Receipt No. Permit No. Issuan a DatEk Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />