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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> is (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic 'on is In by ad to car on b i ss in a jurisdictional area of theVSS oagw Locall Health Distr' t , <br /> ,,Busine Arne {DB Address ,T�, <br /> z Owner_. Address <br /> a <br /> .Firm Partners, Addresses andT ler one mb�ars <br /> a Business Telephone Na.— `��!°ti5 Emergency Telephone No. F <br /> a Z (.P <br /> �Contractor Licence No. <br /> L Applicants Name{Print) Title Date Z <br /> Please check Applicable Cate ry(1-7)and Fill in the Required Information C��} <br /> 1. ❑-PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 11ti <br /> For July 1, June 30, 19 Disposal Sites �7 <br /> Description(Mike/Yr,,—Color) ? <br /> Serial_No.. CAL. License No. CAL. License Renewal No. '• <br /> Capacity Gal., Weights i£ Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD E <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 Lo tion s Test Date/Time <br /> 4. L7 SANITATION PERMIT` <br /> Job Address/L cati ' <br /> Owner ! l Address ITD ^fS <br /> k ,❑, SPTIC TANK ❑ CESSPOOL i LEACHING FIELD <br /> ❑ SEEPAGE PIT 1:1ACKAGE PLANT <br /> LAS PERMANENT ❑ TEMPORARY ❑ NEW^ PAIR ❑ OTHER <br /> 5. 11 CHEMICAL TOILETS For July 1,-June-30,_19 = <br /> r. <br /> Type Construction �- Disposal Site <br /> No. of Units _ Equipment Storage/Cleaning Location(s) <br /> r- 6. ❑ PACKAGE TREATMEN PLANT. For July.1, -June 30, 19 <br /> Operator Name - �"' r " - '� - Where Certified <br /> Plant Location <br /> Plant Capacity A' * r `: No. Units Served <br /> 7. ❑ LAUNDRY For July 1, June 30, 19 <br /> �r ❑ More Than 1, O0 0 54��Ft—, <br /> SIZE: Less Than 1,000 Sq,�F=t.,� � _ <br /> r ❑ DRY-CLEANING, Chemicals Used/Amount/Mo,, ' <br /> HorneowneroflFeensedagent's olgn„turecerHff9sthetollkrurtng:`icery that In the perfOrmanceofthe workforwhichthispermitisissued,tshallnotempkywypose <br /> tt <br /> in such manner as to become sub;ect to wart:nlar.*"M'perrsation laws of ca ifornl� <br /> emnloactor's ,ir,np or sub-ea+Iirac::n ," rt�rF Cer#iti®4 !hi "otlawing_ "t rertity that in the pertormanCe of the work for which this permit is issued,)shalt <br /> V y persons subject tc:vcr° un s ti.il� sa,w., t+�of Cali;or:;i:. <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 of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X , <br /> y a <br /> r FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY _•❑-PER UNIT ❑ PER SITE ❑ EACH t ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31' _ <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> fi DATE DA REMITTED AMOUNT <br /> Col— <br /> FEE. t a [c~+ <br /> LESS <br /> PRORATION f ��•''- <br /> PLUS r <br /> PENALTY <br /> OTHER _ <br /> F OTHER <br /> Received by :. Dafe Receipt No. Permit No, 1s ante Date i Mailed Delivered- <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 99201 - <br />