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Applications Will Bl-processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> ` 1 (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> 1 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of th an Joaquin OC I Health District <br /> yBusiness Name (DBA) Ll Address <br /> aOwner Address <br /> L Firm Pa tners, Addr ses and rs <br /> Telephone Numb <br /> aBusiness Telephone No. Q Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) ,S /r'lC. Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) ^l <br /> For July 1, June 30, 19 Disposal Sites i <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 AddraWLocation 67 3 7 441 le Al <br /> Owner Address 910 <br /> SEPTIC TAN ❑ CESSPOOL 14 LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> M PERMANENT ❑ TEMPORARY 15 NEW ❑ REPAIR ❑ OTHER /—/Z- <br /> S. ❑ 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 /> '13r:180Nnero'3iCen3e:I agF'n;t'S Siilnafl.cre C?'Yt r` :-t,�3§ni!!�lR<;:1t. if r ,:li il '. :; :^,L.. .e:.',._�.1.:.4,'.��hfhlS permit lS issued,.lsha;l not employ any perGOn <br /> in such manner as tr.tecorne,uhipo L -v;}r4tt12ff. 1 1pel1;of inn t.'.te t I:.iii..,:�7£` - <br /> Contractor's hiving or sub-contractin� ;ignat�re cz-ttf e� cf�a ;osiowing: 'I cels, l;at ii;Me peri0l n;ance of tkte work for which',' perp; Is..,..':ed,I sitali <br /> employ persons subject to workman's compensation iavr alifurnln." <br /> I hereby certify that I repar t application a1104 at the work will be done in accordance with San Joaquin County <br /> ordinances,state I s, and r e egu ti sof th an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> �Gltrt d C-dV Y'z< I!E�tv <br /> FOR DEPARTMf NT 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> ,t AMOUNT <br /> FEE <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 />