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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> APPLICATION <br /> (For Nan-Transferable, Revocable, and Suspendable) <br /> � SEPTAGF <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 /> y Busines Name (DBA) Address <br /> aOwner Address dh <br /> Firm Partners, Addresses and Telephone NumbersOft <br /> CL <br /> Business Telephone No. Emergency Teiel ne No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title <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 /> l <br /> Serial No. CAL-.-License No., CAL. license Renewal No. <br /> Capacity Gal.,Weights . -m asures'No. <br /> Equipment Parking Address 1 <br /> 2._11•PUMPER,YARDu,::N <br /> For July 1, t 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- t R.S. or R.C.E.No. <br /> Test Location + Test Date/Time <br /> 4. ❑ SANITATION P <br /> Job Address/Location <br /> O ner Address <br /> EPTIC TANK ❑ CESSPOOL LEACHING FIELD 11 SEEPAGE PIT 11 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 J <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) _V <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ' U" <br /> Operator Name '' Where Certified <br /> Plant Location ss r <br /> Plant Capacity I No. Units Served f <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 /> �IameownerorlicenseA eQenYs signsn�ecerilfieat�eiollrotinr,g:"I the worla for which this permit is issued,l shall not employ any person <br /> In such manner as to become wblort to tMerkman's compensatica iays r:t^atlfornla.' <br /> Contractor's hiring or sub-coritr"ling signature LBrtEfies Trtp fallowing: `I certify that in She perfortil'ahce of ilia w rk tot which this permIUS issued.I shall <br /> employ persons subject to workman's compensation laws of California." <br /> k 1k <br /> I hereby certify that I h prepared this application and that the work will be done in,accordance'with'San Joaquin County <br /> ordinances, state laws, rules Idati s tit n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ; <br /> t <br /> 0FOR 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 /> AM <br /> BASE EXPLANATION DATE DATE REMITTED UNT DUE CHECKED <br /> AMOUNT <br /> Q <br /> FEE S S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER �A <br /> OTHER <br /> ryA <br /> Received by ate Receipt No. Permit No.. Issuanc at Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL E.,P.O.Sox 2009 STOCKTON,CA 95201 - <br />