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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 /> Application is ft7eby made t arty o7business in the jurisdictional area of the Jo uin Local Health District <br /> L Business Name(DBA) -Address!?( U <br /> a Owner Address S7S //i J <br /> Firm Partners, Addresses and Te phone Numbers Oq <br /> aBusiness Telephone No. �_` Emergency Telephone No. <br /> Contractor Licence No. 5 <br /> L Applicants Name (Print) O Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information r <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.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 1XSANITATION PERMIT <br /> Job Address ovation C� <br /> Owner Address _ <br /> SEPTIC,TANK ❑ CESSPOOL ❑ L ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> Id PERMANENT ❑ TEMPORARY ❑ NEW REPAIR OTHER )?6ff1KL- JI'W7-hWK_ -� <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 9 pd <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 1_%,-_ <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 CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowner or licensed agent's sign-5turercrtifi9stt+efotlowing:"Icer0yIha'', °1the perto,"Manceolthe wnrkforwhich this permit isissued,lshall no,employ any person <br /> in such manner as to becolne subject to workman's cotnoe r atim;fnws of C_r,!i,-.1B%' - <br /> Contractor's fairing or suh-contractirf, s:gr Lure cer ifsf-: �t.�o i0owing: '"1 Ce i;; tits;;n tate performance of;?;e work for which this permit,is issued,I shall <br /> employ persons subject to workman's compensation Idws of Cali'arnia.' <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 rules and regulations the S Jpaquin Local Health District. <br /> APPLICANT'S SIGNATURE ' <br /> 1� . a c b_ <br /> 16FOR 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE T£ REMITTED AMOUNT <br /> FEE 4' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER tiL V <br /> OTHER <br /> �� ! 7 <br /> Recei+red by Date Receipt No. Permit No. Issu nce Dat Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 116011 E.HAZELTON A ., .O.8or 2009 STOCKTON,CA 95201 - <br />