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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) e x SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT - <br /> LIQUID WASTE <br /> Applicati n is hereby made to car n basin in the I•n dictional area of th an Jo uin Local Health District <br /> e w r„Business Name (DBA) Address <br /> F , <br /> c Owner - _ _ Address <br /> 2 Firm Partners, Addresses an a hon Numbers ~ <br /> aBusiness Telephone No. — Emergency Telephone No. <br /> Contractor Licence No. <br /> sApplicants Name (Print) _ Title, Date T <br /> € Please check Applicable Category(1-7)and-Fill in the Required Information Y, <br /> • 1.'0 PUMPER VEHICLE PERMIT-REGISTRATION (FOR EACH VEHICLE) c J <br /> ForLJUly 1, 1 JunEi 30,19- Disposal Siies (- <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License'No_• r- 1 CAL. License Renewal No. <br /> Gapacity.---.­ -t:-r . —" 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 f ' R.S. or R.C.E. No. <br /> Test Location 1 Test Date/Time `'1 <br /> 4. ❑ SANITATION PERMIT <br /> Job Add s/L cation c ;I,,C <br /> f Owner `r I Address µms - -- <br /> r• ❑ SEPTIC TANK ❑ CESSPOOL c ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT =sxi <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER > G <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 . "" - - ,� . <br /> Type Construction Dip posal 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 4 <br /> Plant Location <br /> Plant Capacity.__ i ``_ ( No. Units Served �- <br /> 7. ❑ LAUNDRY For July 1, -Jund 30, ;19 <br /> SIZE: ❑"Less Than 1,000 Sq. Ft. .❑ More Than 1,000 Sq. Ft. k <br /> -- <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Ifomeownarorlicensedaper�t'e 9F9oaturecertfffezthcfollowing:"I cert#y thatio the performance of the work for which this permit is issued,f shall rnot employ any person <br /> in such manner as to bo ne sal jact.fo k orkm n'.,+:ompi nsa'lon laovs G€..ahior,if." f �� t <br /> 4 <br /> Contractor's hfrii,q or sub-con:ractinq cif;,�tuce.e�rt;,ss a .ha ±aGa +ing: `;Cs iif,that in t5e-partar llance•a€#jhe work for-whieri'this"permit is issued;I shall <br /> ,employ persons subject to WDI-ktnan's compailsatiol I lays of Cal€atelia.' <br /> I hereb c hat) have prepared this pplica 'on and th the wor will tie done in accordance with San Joaquin County <br />( ordinan to la nd ru s a d regul kions f the an aquin L c I Health District. _ <br /> APPLICANT'S SIGNAT <br /> r I , <br /> FOR DEPARTMENT USE ONLY . �• <br /> w 4 f Y , <br /> Fee Is Due: ❑ ANNUALLY `CL PER;UNIT' ❑ PER SITE ❑ EACH- ❑ January 1 &Received By January 31 ❑ :0y 1V ceived By 1 <br /> F <br /> k REMIT <br /> BASE ' EXPLANATION BILLING REMITTANCE i $ AMOUNT DUE CHECKED <br /> DATE DATE-- - REMITTED AMOUNT <br /> i <br /> FEEcr <br /> : <br /> LESS <br /> PRORATION ... ........ -. .,.._.,....,..,,. _,. i. <br /> w PLUS i� { <br /> PENALTY <br /> OTHER11 <br /> yf/ <br /> v- I <br /> OTHER _ f <br /> Received by - Date Receipt-No` - Issuance-Date t. Mailed Delivered <br /> i - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />