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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />_ APPLICATION <br /> (For Non-Transfeiable,Revocable, and Suspendable) SEPTAL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE - <br /> Application is hereby made to carry on busines in the jurisdictional area of the San Joaquin.Local Health District, <br /> HBusiness Name (DBA) <br /> Address l®fJ. ,;� ;��' - <br /> aOwner - Address w <br /> J Firm Partners, Addresses and Telephone Numbers w <br /> a <br /> Business-Telephone•No. W 6 " . -- Emergency Telephone No.- <br /> Contractor Licence No. zl!! ,y 1!!M <br /> k raS �. <br /> Applicants Name {Print} � � i.'Title. �f Date^ <br /> Please check Applicable Category (1-7)and Fill In the Required"Intormation,lq r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i <br /> For'July1, June•30, 19 '~ = Disposal-Sites -` - <br /> Description(Make/Yr., Color) _ - - in <br /> Serial No. CAL. License No. CAL. License Renewal No. � <br /> Capacity Gal., Weights&Measures No. { <br /> Equipment Parking Address . <br /> I 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 4 R.S. or R.C.E. No. <br /> tt Test Location, z Test Date/Time <br /> 4. Eff SANITATION PERMIT <br /> Job Address/Location <br /> Owner _ Address <br /> CA <br /> ❑ SEPTIC TANK ❑.CESSPOOL 'I LEACHING FIELD+-X)LLSEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT _❑ETEMPORARY). ❑ NEW Cff REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 _ ': P <br /> Type Construction Disposal Site <br /> 'No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT_ Foe July 1, -June 30, 19 <br /> Operator Name - Where Certified=. <br /> i C <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 - _4 <br /> SIZE: Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.'Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner ortWensed agent's signateiro cert'diesthe fafloi v4w 1 reTi if0haf in-the performance of the work for which this permit is issued,I shall not employ any person <br /> In such manner as to beCoMe S0jeCt t0 yr0rkmarr's LampvnSafiUn IaWS 01 <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,I shall <br /> employ persons subject to workman's compensation lawg of California:' <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance.with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin L Healt 01 <br /> District. r <br /> 'APPLICANT'S SIGNATURE X <br /> •� <br /> -FOR DEPARTMENT USE ONLY - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑'PER.SITE C EACH' Cl January 1 &Receive January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION< AMOUNT DUE CHECKED <br /> Y <br /> t DATE DATE REMITTED t• AMOUNT <br /> FEE <br /> f , <br /> LESS <br /> PRORATION - - - - <br /> PLUS <br /> .PENALTY- <br /> OTHER { <br /> { _ OTHER - <br /> Received by Date Receipt No. Permit No IssuancL Date Mailed Delivered <br /> - APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZ£LTON AVE.,P.O.Box 2009 STOCKTON,"CA 95201 <br /> I <br />