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Applications Will fie Processed When Submitted Properly Completed. Be Sure To Sign The.Application. <br /> APPLICATION <br /> h (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE i £" <br /> Application is by ade o bu <br /> to Osine in the jurisdictional area of the SgrLJoaqu Loc .Health is ict <br /> HBusiness Name (DBA) Address d <br /> aOwner a /�r�—_ Address <br /> j Firm Partners, ddresses and Telephone Numbers <br /> aBusiness Telephone No. 4_--r — �� —.Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name Print ` 4' <br /> L (Print) TitleDate <br /> Please check Applicable Category (1-7)and .ill In the Required Informatlon <br /> STRr, <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30, 19 Disposal Sites. . <br /> Description(Make/Yr., Color) li <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal-T�Weights & Measures No. <br /> l <br /> Equipment Parking Address ; <br /> 2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 ' <br /> No. of Vehicles Stored r. # <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 1 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. (� <br /> Test L cation 11 Test Date/Time V <br /> 4. SANITATION PERMIT <br /> it o <br /> J b Address/Lo ation c <br /> Owner LAJ 17 N A 4/ Address <br /> ❑ SEPTIC TANK -El CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑TEMPORARY i NEW ❑ REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS'For July 1,' June 30, 19 <br /> Type Construction k �►` Disposal Site <br /> 'N 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: LEI Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r ' <br /> Home awnerorficenBed agamt'esigm u„eCi1 �:«fcertifythat inthepertvrmartaentthg, rittarwiticAftrfsperntltiaiaaua ,lahallnols to an arson <br /> he <br /> C such manner it to becdrne subject to WOMman's Compensation Paws otCa if01*i.' mD Y yp <br /> Co=riraetor's hiring or sub-cantracyng signs ,cies thn f6lfow+;ng: "1 for W <br /> C2rtily Chaffin Cfie pert0l marlCE [3}the workwhich this permit is ISSued.I shall <br /> employ persons stibjsct 10 workman's compensation laws of Caltterrnia." <br /> I hereby certify that'l have prepare this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules regulatio of t e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PERUNIT ❑ PER SITE .❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ir ' BILLING REMITTANCE $ REMIT - <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> t y DATE DATE REMITTED <br /> AMOUNT <br /> ii <br /> FEE ice ' <br /> LESS i <br /> PRORATIONi'x <br /> PLUS I } QI <br /> 1 PENALTY10 <br /> !1l <br />/ OTHER Il� <br /> OTHER <br /> Received by Date II Receipt No. Permit No, Issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: 'I ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 95201 <br /> I. <br />