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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. , <br /> ` APPLICATION i <br /> ,£ (For Non-Transferable; Revocable,and Suspendable) SEPTAGE _ <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE T <br /> Application is r ade to c on b in s in the jurisdictional area of the San Joaquin Local Hwa Ith Distr' <br /> NBusiness Nam BA) Address <br /> i Owner - Address <br /> j Firm Partners, Addresses and Telephone, <br /> Nu bers <br /> a Business Telephone No. Emergency Telephone No. <br /> Qf .h; �� <br /> � <br /> Contractor Licence No. Gr I <br /> LApplicants Name (Print) Titie is % .. .Date <br /> Please check Applicable Category (1-7)and Fill in the Required information (� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For July 1, June 30, 19 - Disposal Sites --. = - <br /> Description(Make/Yr., Color) .A F <br /> Serial No, CAL. License No. CAL. License Renewal No. f n <br /> Capacity Gal.;Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 a <br /> No. of Vehicles Stored. <br /> .No. of Chemical Toilets Stored ) ' <br /> 3. ❑ PERCOLATION TEST <br /> x i <br /> R.S. or R.C.E. Name R.S. or R.C.E.'No. <br /> Test Location Test Date/Time <br /> 4. ��`SANITATION PERMIT C4 6 r <br /> Job Address/Location I <br /> Ole <br /> w ' <br /> Owner Address ,— <br /> ' <br /> ❑ SEPTIC TANKE], CESSPOOL Cl-LEACHING FIELD —SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY 11 NEW �JZ REPAIR <br /> ❑ 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 i <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals UsedlAmount/MO. f' <br /> Nome owner or t;censed agent's "I certify that in the performance af.the work for which this permit is issued,l shall not employ any person <br /> in SUtb manner as to become stibiect to workman's compensation laws of CaNfornia #_ <br /> Contractor's hirine or sub contracting signature certifies the fallowing: `1 certify that irt the performance of the work for which this permlt is issued,I shall 9 <br /> emptoy persons subject to workmaWs compensation laws of Galifortfia°, f <br /> he work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this application and that t , <br /> ordinances, state laws, and rut d regulqPons of t Wan Joaquin Local Health District. 4 <br /> APPLICANT'S SIGNATURE X _ 1 <br /> FOR 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 DATE REMITTED AMOUNT <br /> FEEq J0 <br /> a <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY i <br /> <. OTHER <br /> OTHER _ <br /> •4 , <br /> 1. Received by Date Receipt No. Permit No. Issua a Datel Mailed Delivered ; <br /> APPLICANT'RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />