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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 4 - <br /> APPLICATION <br /> k r (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> r_ ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati W is hereby ade t gar n bus' a int jurisdictional area of the SAV Joaquin cal Health District <br /> .Busine — (DA. Address NO 7 <br /> aOwne Address <br /> Firm Partners, Addresses and Tel p o LVumbers <br /> 1 a. Business Telephone No. - - Emergency Telephone Na <br /> I Contractor Licence No. -- <br /> Applicants Name (Print) w Title . - .Date Y <br /> Please check Applicable C ory (1-7) and Flil In the equired Information <br /> ie❑ PUMPER'VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) T' <br /> For July 1', .=June 30,19. -._- Disposaf"Sites } <br /> Description{Make/Y(., Color) r <br /> Serial No. CAL. License No. CAL. License Renewal No.;! + '`• <br /> t Capacity ^Gal., Weights& Measures No. _ <br /> Equipment Parkiing'Agdress �a V <br /> ..2.=. 0 PUMPER YARD- <br /> For <br /> ARD <br /> z. <br /> For July,,1, M1 -Ju e 3C1, 19 "7d <br /> No. of Vehicles-Stored..,. <br /> 4- - .. & <br /> No. of Chemical Toilets Stored t ' <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Testi Location Test Date/Time <br /> 4. 9 ocSANITATION PERMIT <br /> Job AdyesLocation r ' <br /> Owner Address _ <br /> Il�EPAN ❑ CESSPOOL I AOHING FIELD ❑ SPAGE PIT ❑ PACKAGE=PLAhLT . <br /> '�ERMANENT ❑ TEMPORARY REPAIR <br /> 5.+❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction ft .�. Disposal Site, <br /> No. of Units EquipmeniSiorage%Cleaning Locat o(sJ+ �• '; <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19. y v <br /> Operator Name -- 3 Where Certified <br /> Plant Location I <br /> Plant Capacity € No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 Y } <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. f <br /> '❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owneror licensed agent's sig nature certifies thefollowing:''1 certify that in the performance of the work forwhicti this permit is issued,l shall not employ any person <br /> in such manner as to hecome subject SQ xorl ma"r's compansatian laws of Caldor IIS '"`"` " '" """' <br /> crtas <br /> raator's hiring or sub-contracting s:gnatum cerWi•�s the ioitowind�. "1 certify that in the performance of the worjk for which this permit is issued,I shall <br /> o� <br /> employ persons subject to worknlacis cumpensat:on laws of Califoinia." ! <br /> � t 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 ru es and rea ns the San Joaquin Local}Health District`. <br /> APPLICANT'S SIGNATURE X � r 1 <br /> FOR DEPARTMENT USE ONLY�_.., <br /> ` Fee Is Due: 11 ANNUALLY ❑_ PER UNIT El PER SITE ❑ EACH 'El January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> t DATE DATE REMITTED . AMOUNT <br /> FEELESS,... tin— <br /> PRORATION - <br /> PRORATION <br /> PLUS 1,�. i a ♦1 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No_ Permit No. flssuanc6 Oate Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />