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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �_.y i✓ � (For Non-Transterable;-Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE M <br /> Application is hereby made to carry on u ine "n the jurisdictional area of.the,San Joaquin Loc ealt, i�rict <br /> rn Business (DBA) Address <br /> aOwner -_Address <br /> 0 Firm Partners, Addresses and lephone Numbers � �Z� , <br /> { a Business Telephone No. 'ZZ' . _s- Emergency Telephone No.., —� <br /> Contractor Licence No. t,- <br /> �2yLApplicants Name (Print) Title -� Y — ; Y Date ✓a <br /> Please check Applicable Category (1-7)and,Fill in the Required•Information,!t <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 r <br /> For July 1, <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. ❑ SANITATION PERMIT` <br /> Job'Addres`�cation p <br /> 4 Owner Address <br /> SEPTIC TANK ❑ CESSPOOLS- ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> `:,PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> -5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site - <br /> s <br /> No. of Units Equipment Storage/Cleaning Location(s) w <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ! <br /> Operator Name ,t s"• " Where Certified <br /> Plant Location { _ <br /> Plant Capacity No. Units Served R <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,' ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> .No 1reownertill,litermodagent's skmaturesertMesthefaflBaring:"l"rt9lythatinthepEtformiInceofthEworlt for w ichthispermitisissued,lshallnatemployanyperso:t <br /> in such manner as to became subject to work mans corrtpensati�on laws of California." <br /> ContnK"r'e Md" m Wa&t Coatractleg stgnaturw eertlHesfie fammkily; -1 eeldy that in the performance of the work for which this permit is issued,I shall <br /> emptoy persarts subject t»workmat►'s compertsatiDl laws of Caflfmnta.• . <br /> I hereby certify that I have prepared this application and that the work will be done in adcordance with San Joaquin County <br /> ordinances, s ws, and rules anis regulations of the San Joaquin Local 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 /> • BILLING REMITTANCE ' $ REMIT <br /> BAEXPLANATION i; <br /> } <br /> SE AMOUNT DUE CHECKED <br /> DATE DATE - REMITTED AMOUNT <br /> FEE-1k <br /> LESS ' <br /> PRORATION'. <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1. OTHER <br /> Received-by I D to l ..Receipt No. - Permit N Issuance ate Mailed Deli"vererk, <br /> APP C_A4T_-RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMITISERVICES 1691 E.HAZEL .,F.O.Box 2909 .',STOCKTGi41A 95201��, <br />