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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable;-Resroca-ble, and Su spendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 0 LIQUID WASTE <br /> t <br /> Application is her y made to ca on business in the jurisdictional area of the.San Joaquin Local Health District,; af, <br /> ,F Business Name (DBA) Address <br /> z Owner Address <br /> Firm Partners, Addles e a elephone Numbers <br /> aBusiness Telephone No. _Emergency Telephone No. <br /> k Contractor Licence No. .�. <br /> Applicants Name (Print) -Title Date <br /> Fes: <br /> Please check Applicable Category (1-7)and Fill in the Required Information ,. ,4 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) y E <br /> For July 1, - Jdne 30;19. w.--'"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. e <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT `..0 ' - • r <br /> Job Address/Location dtie <br /> .Owner Address <br /> SEPTIC TANK CESSPOOL ❑'L ACHING FIELD ❑ SEEPAGE Pli—'O PACKAGE PLANTAht <br /> ` <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER - g <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 4 4' <br /> Operator Name - - Where Certified. <br /> "Plant Location F <br /> Plant Capacity _ No. Units Served f : <br /> 7. © LAUNDRY For July 1, -June 30, 19 - '• • - - '-' t <br /> ;SIZE: 0Less Than 1,000 Sq" Ft., ❑ More Than 1,000 Sq. Ft. 'L Or <br /> n ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ' z <br /> Kauchmanrorifcensadegeubjecttowrkmn,sCoMreiSatWntaws01rlifq lflstinthopErforManceoftheworkforwhichthis p0m'rtisissued,Ishalinot employ any person <br /> In such manner as to become subject to workman's colnpensatk►a1 taws of Ga6foi nia., <br /> ContrRctor'1s Wring °► lFUtf 4 t1lrtrACtirrg ii0l0t rerdiles The tollowi. 1 cer'st:y.isf t:r i11 performance of the work for wflich this permit is issued,I shalt <br /> employ persons subject to workman's oTnpeltsatlotttaws of Cali€;,rrtia.- <br /> 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 rules and re ulations f the'San Joaquin Local Health District. <br /> .t _ <br /> APPLICANT'S SIGNATURE"X <br /> 61 : <br /> + fi FOR DEPARTMENT USE ONLY - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION .DATE r DATE REMITTED AMOUNT DUE CHECKED <br /> • AMOUNT <br /> ' <br /> FEE7 S <br /> LESS s <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER s - <br /> _. . <br /> 3 . <br /> Received by - Date Receipt No. Permit No, Issuance Date Mailed t Delivered_ - <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMITISERVICES-'"-" 16011E.HAZELTON AVE.,P.O.Box 2009" STOCKTON,CA 96201 "' <br />