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Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheAppucauon. <br /> APPLIi TION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on busin sin the jurisdictional area of the San Joaquin Local Health District <br /> HBusiness Name (DBA) 0Address!��. <br /> z Owner Address <br /> a - <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date o <br /> Please check Applicable Category(1-7) and Fill in the Required I ormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l <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. Od SANITATION PERMIT - <br /> Job Address/Location 132--;7,V <br /> Owner Address <br /> ® SEPTIC TANK ❑ CESSPOOL 14 LEACHING FIELD Iff SEEPAGE PIT ❑ PACKAGE PLANT <br /> 19 PERMANENT ❑ TEMPORARY N NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 J <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 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 licensedagant's signa tum certifies the frlllowinry:"I cerci y that in the perfOrmanccOf tbewOrkfofwbfctlthis permit is issued,tshall not employ any persen <br /> in such manner as to becama subject to workMAn's :imp^t aticl'fat°�s Ot C7 iferr"Ta ' <br /> Contractor's hiring or sub•contrainVna a;irn2ture Eertifif:s lira following: `l certify that in t.1e pertormanee of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compens�tlor+laws of Ca2itornia." <br /> hereby certify that I have prepared thisfapplicationand that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaqui ocal Health District. <br /> APPLICANT'S SIGNATURE X ` <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 /> FEE <br /> LESS <br /> PRORATIONPLUS <br /> PENALTY G•" , py <br /> OTHER V. <br /> OTHER <br /> Received by Date Receipt No. ,,K, PermiIND. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952x1 <br />