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Appucanons vvtn tie erocessea wnen buornmea t•ropeny%.;ompiezea. tie bure 10 blgn 1 ne %ppncauun. <br /> APPLICATION <br /> or Non-Transferable, Revocable, and Suspendi SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT`S <br /> LIQUID WASTE <br /> Application is by ade to 00 busine in the jurisdictional area of the SaaraJoaqui iLOC Health DIS ict <br /> •y Business Name (DB ) a Address <br /> z Owner kddress p <br /> a <br /> Firm Partners, ddresses and Telephone Numbers <br /> -r Business Telephone No. �'� Emergency Telephone No. <br /> Contractor Licence No. \ <br /> a Applicants Name (Print) Title ¢, Date <br /> Please check Applicable Category (1-7)and ill 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 /> Test L cation Test Date/Time <br /> -4�SANITATION PERMIT C <br /> J/_ <br /> b Address/Lo ation / ��" <br /> Owner -V 10 S Address Ax <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> _-.❑ PERMANENT ❑ TEMPORARY01 NEW ❑ REPAIR OTHERlf <br /> 5. 11CHEMICAL 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 /> _0 DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Homeowner or licensed agent's signature oertffies the following:"1 cert Nv that 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 workman's compensation laws of Ca ifornigr, <br /> Contractor's hiring or sub-contracting sipnaturo certifies the foifowing; 'I certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman s compensation laws of Calitornia." <br /> W I hereby certify that I have prepare this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules - regulatiopg <br /> of t San Joaquin Local Health District. <br /> .APPLICANT'S SIGNATURE <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE y- <br /> LESS /I <br /> PRORATION <br /> PLUS A! <br /> PENALTY <br /> OTHER J <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />