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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business!Name (DBA) Add reps <br /> a Owner D &Address,C ' <br /> L) Firm Partners, Addresses and Telephone Numb rs <br /> aBusiness Telephone No. Emergency Telephone No. � <br /> 1 Contractor Licence No. <br /> �Applicants Name (Print) L!e. Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information l <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 S 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.G.E. No. <br /> Test Location Test Date/Time <br /> 4. °�L SANITATION PERMIT <br /> Job Address/Location I'VL 14 to C�4 3 <br /> Owner Address,2/ Sy. Q D � <br /> ASEPTIC TANIt ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT w <br /> ❑ PERMANENT ❑ TEMPORARY IZNEW ❑ 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 t 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 cra"worTicensed agent's Agnature certifieetl,efoitowing:"l certify that in the performance of 1Re work fdr whieh tftis permit is issued,I Mail not employ any person <br /> in such manner as to become suhfect to workman's compensation laws of California " <br /> Contractor's It" w sub-contracting signature certifies the following: A certtfythat InthC performance of the work for which this permit is issued,I shall <br /> employ persons stlll;eCt 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, ad rules and reg I tion the San Joaquin Loc Health District.. <br /> 1" <br /> APPLICANT'S SIGNATURE X <br /> f <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 PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> V <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date I Receipt No. Permit No. Issuance D Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.14AZELTO O.Box 2009 STOCKTON,CA 952pr <br />