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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 hereby made to carryon business in the jurisdictional area of_th_e San Joaquin Local Health District <br /> OF Business Name (DBA) l Addre s. w16 <br /> aOwner Address _ ., <br /> i 9 Firm Partners, Addresses and Telephone Numbers <br /> i a Business Telephone No., - c Emergency Telephone No. i <br /> Contractor Licence No. w <br /> t-Applicants Name (Print) - Title - Date <br /> Please check Applicable Category(1-7 and Fill in the Required Information <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 r <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 <br /> iq <br /> Job Address/Location �� <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL. ❑ LE=ACHING FIELD ❑ SEEPA PIT-�"❑-PACKAGE PLANT - <br /> ❑ PERMANENT ❑ TEMPORARY ❑ fJEW ❑ REPAIR OTHER / UJ' <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 <br /> Operator Name Where Certified.._ <br /> Plant Location <br /> Plant Capacity -- Na. 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 /> Nomeowm ertieensedagenrsalowtuleaartifieathefollowing:"Ireriifyyth3lintheperformanceoftheworkferwhichthispermitisissued.l00notemployanyperson <br /> in such manner as to become subject to workman's compensation laws at California." ' <br /> Contractor's hiring-or-eub.conVsv4ng signature certifms the toSowing.. '1 certifylttat in.the performance of the work for which this permit is issued,I snail <br /> employ persons subject to workman's compensation taws of California.' ¢ <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules a d regulations of the gan Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -- - <br /> r 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE" - DATE REMITTED AMOU <br /> AMOUNT DUE CHECKED <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS v-4- <br /> PENALTY <br /> OTHER r <br /> A OTHER <br /> Received Date Receipt No. ,, Permit No E Issuance Date Mailed Delivered <br /> APPLI NT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH'PERMIT/SERVICES' 1'1601 It.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201'- <br /> - - - <br /> ,a' <br />