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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) SEPTAGF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in thejurisdictional area of the San Joaquin Local Health District. <br /> rn Business Na (DBA) Address - <br /> z Owner—..--. "Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No., Gj�f y—�3D Emergency Telephone No. <br /> Contractor Licence No. 30 �7 <br /> L Applicants Name (Print) M 5 �� Title4 �'2l i1t Date 3 —!�Z— ,9 <br /> \ Please check Applicable Category (1-7)and Fill in the Required information <br /> V. ❑ 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 x <br /> • r <br /> For July 1 June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored _ <br /> 3. ❑ PERCOLATION TEST i. ��•;� <br /> .R.S. or R.C.E. Name R.S. or�'R.C.E, NO. <br /> Test Location Test Date/Time <br /> 4.)tl SANITATION PERMIT p/J �t <br /> Job Address/Location MO �VL]9 C <br /> Owner 5>4rs?P p Address ]S <br /> I.SEPTIC TANK ❑ CESSPOOL 'I -LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> .❑ PERMANENT 11TEMPORARY NEW 1:1REPAIR J<OTHER AbGLy}i ov014- <br /> E 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site ;•- - . ! , _ <br /> No. of Units Equipment Storage/Cleaning Location(s) G <br /> B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name -- - Where Certi fled <br /> Plant Location g <br /> Plant Capacity' No. Units Served <br /> i 7. ❑ LAUNDRY For July 1, -June 30, 19 t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 1 Frofne ownerorlicensed agent's 6ignaturecertifFesthe following-"I terrifyy that in the performance oilhe work tar which this permit is issued,I shall not employ any person <br /> in such manner as to become subject to workman's colrperrsa?ion lows nt C2tiforni; <br /> Contractor's hiring or sub-contracting signature certifies the following: 'i certify that in the performance at the work for which this permit is issued,']shall <br /> employ persons subject to workman's compensation laws of Catiiaml,." <br /> I herebyscertify"that I have this plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rules and eg of the aqui L th Di r ct. <br /> APPLICANT'S SIGNATURE.x <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due- ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH anuary 1 &Received By January 31 ❑ July t &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING R TTANCF ' $ - •AMOUNT DUE CHECKED <br /> - -:t DATE DATE - REMITTEn't t AMOUNT <br /> FEE <br /> A . <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - U <br /> OTHER <br /> k <br /> Received by ❑ to Receipt No. Permit No. Issuance Date Mai ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />