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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION I r Ifl i <br /> G� (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in thejurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) Address <br /> a Owner Address S��9E <br /> �- <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> 11 Contractor Licence No. —r� - <br /> 4ApplicantsName (Print) n �iA L /oSe/� Title Z/&Ylt�� Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) e <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. 63 PERCOLATION TEST <br /> R.S..w R.C.E. Name,Q nn ��. / OS R.Grer R.C.E. No. /SQL <br /> Test Location -ee& Teat Date/Time <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 4 <br /> S. ❑ 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 /> Home owner orkcansed agenPssignaturs ciurvi k,the following:"1 certify that in the performance of thework for which this permit is issued.)shall not Employ any person <br /> In such manner as to become subject to workman's compensation taws of Cafifnmia' <br /> Contreemr'a tiring or auhconvacting sigriartrm certifies the follorAng: "I certify that in MB performance of the work for which this permit is issued.I shall <br /> employ persons subject to workman's cumpensariun laws of calitomia:' <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 <br /> r/rry,'as and 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/ &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT—CIC <br /> FEE 06 ( !� W <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER h <br /> OTHER ! <br /> {- 104 <br /> Received by Dale Receip3t No. Permit No. Imuence Date Mailetl Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sea 2009 STOCKTON,CA 95301 <br />