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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) SEPTAGE <br /> �1 ENVIRONMENTAL HEALTH PERMIT <br /> Icy LIQUID WASTE <br /> Applica jon is hereby ma a to carry on usin s i he j77'sdictional area of th an Joaq n Local Health Dis ct , <br /> y Busine =(DB ' Address;. A� �� <br /> z Ow ne Address <br /> a <br /> J Firm Partners, Addresses and T hone mbers <br /> 7_� <br /> I Business Telephone No. Z/Q:!�:= Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) Title Date I <br /> Please check Applicable Roe7ory (1-7) and Fill iAhe 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 i, 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. 6 SANITATION PERMIT ` Q <br /> Job Address/ ocation <br /> Ow r ' Address A <br /> SEPTIC TANK ❑ CESSPOOL 2—LEACHING FIELD EEPAGE PIT ❑ PACK GE PLANT �n'f <br /> ❑ PERMANENT ❑ TEMPORARY U 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 <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 /> Home owner or licanserl agent's signat.rrn Aertifics the fopowing:"I certify thni'n 1'e performance atthe lnork for which this permit is issued,I shall not employ any person <br /> in such manner a;:to became subject t w,lnr„a;=';;;on cnsaiiu: 13u/s of Cali`orr;p ' <br /> Contractor's hiring or sub-contracting ;ignotuse coniffFs die 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€aws of Caiitornia” <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, a rules and reg ations of 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE � <br /> LESS <br /> PRORATION ` <br /> PLUS 1' QJ <br /> PENALTY 1S <br /> OTHER �_ l <br /> r <br /> OTHER <br /> S 6-s a ?� <br /> Received by Date Receipt No Permit No ssua a 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 />