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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For <br /> a (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic n is hereby made carry on business in he juri fictional area of the ,nny JoLa }in Local He Ith Distric <br /> Busine ame (DBA Address rL <br /> aOwner Address.—� <br /> Firm Partners, Addresses and Telephone umbp.M <br /> aBusiness Telephone No. D Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print} Title <br /> Date EL o <br /> Please check Applicable Category (1-7) and Fill in the 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 1 <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�L�ation Test Date/Time <br /> 4. � SANITATION PERMIT <br /> Job Addre Locat' 9,9 <br /> 1 <br /> Owner * Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT I; <br /> a-PERMANENT ❑ TEMPORARY ❑ 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 /> C3 JRY CLEANING,Chemicals Used/Amount/Mo. <br /> cora186wgerorliaensedagenrestgmtureeertfHeathefol :1-certiytwin the erforrnanceefthework for whichthls ermftisissat'd. �`raRRntem It> <br /> In such manner as to trecome subject to workman's compensation laws of Cafifomia.' p _ p ' fs Y any person <br /> Contractori hiring or eubcenirectsng sigmtlwe certaSes the - 4 CertifY that in the periorrrance 0"".,ark for'r;rich l;.°: re: ;ii is i_�cCL,I shall <br /> employ persons subjeCt to worlcrun's compensation laws of Cafitorma.' <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, aN rules arA.reolations 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 &Recewed By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ f <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE qc� <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 0- <br /> Received by Date Receipt No. Permit No. I u nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bow 2009 STOCKTON,CA 95201 <br />