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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application s <br /> r APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic is hereby ma to car 9n business in e' rical Health <br /> sd' tional area of theme District / E <br /> NBusines ame (DBA Address_ <br /> i Owner Address <br /> d <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. C)c� Emergency Telephone No. <br /> K L La <br /> Contractor Licence No. �, Date <br /> Applicants Name (Print) Title —I <br /> Please check Applicable Ca gory(1-7)and Fill in Ahe Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Imo' <br /> For July.1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) _' <br /> -� <br /> CAL. Lice,se Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> �1 <br /> 2. ❑ PUMPER.YARD <br /> rFor July 1, June 30, 19 s <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ' <br /> 3. 11 PERCOLATION TEST - - -- <br /> F R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location <br /> Test Date/Time I <br /> 4" 9SANITATION PERMIT j <br /> Job Address/L atio _ d <br /> Address � �T <br /> ❑ PA KALE PLANT <br /> L�SEP TANK 11 CESSPOOL <br /> ®'LEACHING FIELDEEPAGE PIT <br /> 19 PERMANENT ❑ TEMPORARY dKEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 0'- <br />� Type Construction , <br /> 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 /> ,. <br /> Plant Location <br /> Plant Capacity -- — - - -- - No. Units Served <br /> I 7. ❑ LAUNDRY For July 1,.;l une 30, 19 W° <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowner orlicensed ogoWs elgr+aturoce.tiiiestMtofl orrtng:'9 certify that in the performance of the work for which.this permit is issued,100 0 net em ploy aftypersdn <br /> in such manner as to become SoNect to wovkma115 compensation lays of Calito;rlia ' <br /> t Contrames hiring or lm *nGv.mg. 'i czrtiEy-°; _;i t;l i;;e,erfo. an :t`the vlork for whichthis permit is issued.I shall <br /> cmploy persons Subject to WCi iitii.l!'S cornpellsatierl,is wr,of <br /> sz -fir" <br /> 1 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 reg lations 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 &ReceivedREMIT my 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED -'AMOUNT <br /> 1' FEE Vv <br /> LESS <br /> PRORATION <br /> PLUS , <br /> PENALTY ' <br /> OTHER <br /> OTHER 4 " <br /> f Received by _ Date. Receipt No.. - Fermi,No. 1 suance ate Mailed Delivered <br /> 1' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 e.HkZELTON AVE.,P.O. , 009 �STOCKTON, 952 <br />