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Applications Will Be Processed When Submitted Properly Completed. tae Sure 10sign rrtes,Fpg0tTWT1. <br /> APPLICATION <br /> (For Non-Transferable, Revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ~ Appl ication i ereby made„�o carry on business ina jurisdictional area of the an Joa uin Local Health District <br /> OF Business Name (DBA) r <br /> f✓ v Address <br /> z Owner Address u _ <br /> j Firm Partners, Addresses and Telephone Numbers �} <br /> CL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Intor anon <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. GAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> I Equipment Parking Address -- <br /> 2. ❑ PUMPER YARD y ,. <br /> For July 1, <br /> June 30, 19 <br /> No. of Vehicles StoredNo. of Chemical Toilets Stored ,, R <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name a R.S.or R.C.E. No. <br /> Test Location f Test Date/Time <br /> 4. % SANITATION PERMIT7 <br /> Job Address/Location 00, <br /> - 6 <br /> Owner . �[/t - �o - A dress �* <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 13 SEEPAGE PIT ❑ PACKAGE PLANT ��JJ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW IX REPAIR ^ ❑ OTHER y; <br /> 5. ❑ CHEMiCAL TOILETS For July 1, -June 30, 19N <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 /> Y _.Where Certified <br /> Operator Name <br /> Plant Location , <br /> t 3 Na. Units Served <br /> Plant Capacity - <br /> 7. ❑ LAUNDRY For July 1,:June 30, 19 a " <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.,-'' _ 4 t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowner or licensed agent's si9rtatu*s cert#les thafoHov+iing:"I orlifv That in the perforrnanceol the work for which this permit is issued,l s half not employ any t ersog <br /> in such manner as to becojji.2 sLlbject tc workman's compensation h4Ws 01 Galjlcrrllr <br /> Contractor's hiving or sub-cantrao*ig signeture-.eertifees th$,fallowldg: "t certifythaf in ifie perfDrrtanee of the v:nrk fDrv:tlietl this permit'is iss`Jed,l shall <br /> employ parsons subject to vrarkmarfs compensation laver'al California" <br /> . <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 rILLes and re gut tions of the S aquin Local Dis t. <br /> -APPLICANT'S SIGNATURE <br /> # fOR*DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received REMITuly 31 <br /> BASE 3 EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> # DATE DATE REMITTED AMOUNT <br /> 4,0 <br /> FEE * - 46 <br /> -� -Si <br /> LESS <br /> PRORATION <br /> PLUS a ; <br /> PENALTY <br /> OTHER <br /> OTHER �.-�-• w <br /> ? Date Receipt No. Permit No. ssuan a ate Mail Deliver <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZECTON AVE.,P.O. ox 2D09 STOCKTON,CA 952D1 <br />