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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> F ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is herebo carry o siness in tV jurisdictional area of the San Joaquin Loca}Health ' trio <br /> y m <br /> yBusiness Name (DBA) 11�2— Address_, _� <br /> i Owner Address U <br /> d <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.X46� 14! Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date . l/ Z 5 92- /rFS16,,'' <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 <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.G.E. Name R.S. or R.C.E. No. <br /> Test Lo n Test Date/Time Q� <br /> 4. SANITATION PERMIT <br /> Job Address/Loc to 10 <br /> Owner "a- l 2, Address o r r <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PAC GE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR El 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 /> ❑ DRY GLEANING, Chemicals Used/Amount/Mo. <br /> fIORle ONTP_f orlicCnsndA LR'-"••!;c,. �,,.,_ �_F...4„�„�Fw .,1 �3:� '-,r 4f �rt� f 1 1 u:; <br /> this permit isissued,Ishall'not employ any person <br /> in such matiner as to baccate tobfef. -,; <br /> Contractor's hiring or stsu-cor.^P'1rf,'7g sivnetare een,;-a,` fodovvrad:`A certi,y that m the performance of Me work for wttich this pormit is issued,I shall <br /> employ persons subject to poi krnaa's�o,�� saturn lav,.,of Call,o;, <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, and rule d gulati s ofthe an J aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> B'3 <br /> FOR DEPARTMENT S NLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATIONAMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �3- J 5 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> . ri <br />