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APPLICATION <br /> r (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ApplicatAh1n� the Jurisdictional area oft 1J ` H�ah DC* '�. n2��Business Name (DBA), k}e Addressq <br /> f <br /> z Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. �Sdp a Emergency Telephone No. <br /> Contractor Licence No. i� LL'13 <br /> Applicants Name (Print) Title Date Z—Z,z,•� , <br /> ,a 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 <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 /> Tet ocation Test Date/Time <br /> �4. 0,SANITATION PERMIT , <br /> Job Address/Location <br /> w er Addre <br /> rPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT 11 PACKAGE P ANT <br /> _&s RMANENT ❑ TEMPORARY EW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 - <br /> r <br /> Type Construction Disposal Site s. <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 cj� <br /> Operator Name - Where,Certilied , <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 own9r or Geensod aeem'-atgneturo ceniflestMtdbwMg:7 Certify that in the performance of file work for which this permit is issued,I shall net employ any person <br /> in such manner s tc become suuiecLe Pm;kman's Cllnlpematiea laws of Ca ifomk.' <br /> Com.eecO"s hiring or sub<mtmcttna signature nertffies the follovving; "I certify that in the performance of the work for which this permit is Issued,I shall <br /> employ person SiftCf to workman's Compensation laws of California." <br /> I hereby certify that I hav- prepared this applic 110 nd til a Coo wilt be done in accordance with San Joaquin County ,L <br /> ordinances,state laws d ;and regu ions i S Jo uin Lo I Health District. <br /> r APPLICANT'S SIGNATURE X <br /> f <br /> f <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 -8 C� a � <br /> LESS <br /> r PRORATION <br /> 'PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> r Received by Date Receipt No. `Permit No. [tauanm Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.1 211109 STOCKTON.CA 952111 - <br />