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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 /> 4 Application is hereby ade to cafry on business in the jurisdictionalareaof the Sa Joaquin Local Health District: <br /> HBusiness Name (DBA) - Address p <br /> 4 Owner Addre55 <br /> J Firm Partners, Addresses and Telepphho,�ne'' cumbers <br /> M Business Telephone No. eIA5:z Emergency Telephone No. <br /> -Contractor Licence No. <br /> Applicants Name (Print) �`Z• J�dGGC`�� -- Title — Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information t y <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. ^E <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ' <br /> For July 1, June 30, 19 <br /> Na:of Vehicles Stored +h <br /> No. of Chemical Toilets Stored <br /> j 3. ❑ PERCOLATION TEST t <br /> I R.S. or R.C:E. Name ; R.S.or R.C.E. No. <br /> Test Location !�• Test Date/Time / <br /> 4. SANITATION PERMIT ? ' l <br /> Job Address/Location_ A4 / <br /> d <br /> Owner I CT P /1027 Address -.w <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT- <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ C{ <br /> HEMICAL TOILETS for July 1, -June 30, 19 (i <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 � t f <br /> OperatortName Where Certified^' <br /> Plant Location - 1 <br /> Plant Capacity No. Units Served ! <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. � <br /> Nome owner or licensed agent'ssi naturecertiffeirthefollswtrtg:"lrertifythati�!7eperfcrmzncc,oktheworkfor- this permitisissued,Ishall not employ arty per <br /> � <br /> in such manner as to become sublet to worRnr.1•:•'s co�.rnensatien laws of Ca,ito[mi' <br /> cont►actor's MrirT or �b-Ca[ttraelJng Sigr attrr� ce,titses the touawing:•`�I c tify..ih�in;the�ertormance Gf the work for rihich ttlis permit Is issued,I sP alE <br /> Employ persons Sub)ect to Workman's campansatiun laws of California.", t , <br /> r ` I hereby certify that I have prepared this-ads licaiion and that=the work Will9be done in1 accordance with San Joaquin County <br /> F ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distrlc ..- y <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USEONLY <br /> Fee Is Due: 13ANNUAL-LY ❑ PER UNIT_ ❑ PER SITE ❑ EACH+ ❑ January 1 &Received By January 31 ❑ Ju1y 1 &Received By July 31 <br /> f BILLING REMITTANCE $ I REMIT <br /> Y BASE EXPLANATION AMOUNT DUE CHECKED <br /> .-... <br /> t DATE--..._:.:..-w---�.-.DATES.. . REMITT.ED�. .. ......�,� AMOUNT <br /> FEE '�'ti. f ` <br /> LESS t # <br /> PRORATION ; f <br /> PLUS t <br /> PENALTY _ - - <br /> OT�IER 'a <br /> CTRL <br /> t� r <br /> Received by Date Receipt No. .� 'Permit No. Igsuarice Date Mailed Delivered ` <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 --STOCKTON,CA 95201 <br />