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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> Z/ ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Distri t <br /> Business Name (DBA) Address Z�� �' �q /n h <br /> a Owner �Y6w7/6 �/ Address <br /> J Firm Partners, Addresses d Telep one Ilumber <br /> CL CL Business Telephone No. �O 1. — Emergency Telephone No. <br /> Contractor Licence No. _ 1 <br /> < Applicants Name (Print) ����� C oSG Title Date - <br /> Please check Applicable Category (1-7) and Fill in the Required Information <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 <br /> For July 1,_ June 30, 19 <br /> No. of Vehicles Stored —No of Chemical Toilets Stored <br /> 3. P1 PERCOLATION TEST �� <br /> R.S. or R.C.E. Name Rig;-or R.C.E. No. / <br /> Test Location .S�E� eel Ali' Test Date/Time i20 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location - <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ 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 /> 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 /> Noma owner orlicensed agent's signature eertiReatty falMwhM1:"f rcr!ity tbM In the performance of the work for which this permit is issued,I shall not employ any person <br /> in such manner as to become subject to v.,orkn..tt! rc^1^en '.,i- t. ' <br /> Contractor's hiring or sub-contraerinp sognatgre .;;,re.,, tit, :hat in Ihw performance of the work fcr which thit,permit is issued.I shall <br /> employ persons subjoet to workman s componspuuA laws of IJaliiorttia, <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, !ar1d rules and regulations of the Soman 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 /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE f) P ✓ d 1,2,42 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> A <br /> R cefved by Date Receipt No. ermit No. -Issuance Date Mailed D <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 <br />