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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 /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is herby mad to carry on busine s in,�hejur dictional area of the an Jo uin Local Health District <br /> ,r Busines arae (DBA) Address <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a ���Business Telephone No. � _ Emergency Telephone No. <br /> Contractor Licence No. ZZ <br /> Applicants Name (Print) per- P Title V, Date Z <br /> Please check Applicable Category (1-7)and Fill in th 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 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. <br /> Test Loc ion Test Date/Time _ <br /> 4. RISANITATION PERMIT �] <br /> Job Addres /Location <br /> Owner Address d �s S 2Zo <br /> ❑ SEPTIC TA K ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> L PERMANENT ❑ TEMPORARY ❑ NEW 2-REPAIR' �'6 H t sctr✓��D <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. r <br /> VPW*oW to ar"Con"d agent'sto"that In IfIePerfOringnoe of thawork for which this P$Tmitls lspjw,I shall not employ any person <br /> b such manner as is became subject to workman's compensation laws of California,, <br /> %vntnctor's 11!$ng or sub-cantrectinp lripnerjre certW16ethe fallovAng; 1 certify that in the performance of the work for which this permit is issued,I shall <br /> 111111110Y persons subject to workman's compensattoll taws of Cal0orala.- � <br /> I hereby certify that f'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 ula 'ons 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 ly 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED MOUNT DUE CHECKED <br /> AMOUNT <br /> 1 O� <br /> FEE J 6 <br /> LE5S <br /> PRORATION " <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No Issua ce Date Mailed Deli a ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br />