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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 /> ENVIRONMENTAL HEALTH PERMIT uq(9LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) Address <br /> i Owner fix_ `fAY(.o1L Address <br /> Firm Partners,'Addresses and Telephone Numbers <br /> a. Business Telephone No. fY8 (��� Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) L-�4� � L�4Title 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 <br /> No. of emical Toilets Stored <br /> 3. L PERCOLATION TEST <br /> R.S. or R.C.E. Name ��'� CA- R.S. or R.C.E. No. <br /> Test Location 4to/Time <br /> 4. ❑ SANITATION PERMIT 4! jfC✓ �S �f' «✓ t /Z.�r <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 or licensed apont's rtgnat irn oen3fims the follovring,"I reflif"1140!ntimlerformanee of the work for-which this permit is issued,I shall not employ any person <br /> in such manner as to become sub}act tc•:iork-:;,-n't,,r mpensalixi Ins:: 1`Csri; <br /> Contractor's hiring or sub-oontrer,._Sn;a certi!es 4 tui-tify that in the perform3nc2 Lt the work for which this permit is Issued,I shall <br /> employ persons subject to workman's compensa icr iawas of Califon.ia." <br /> I hereby certify that I ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la an /ss and regu ion§-ooff to San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <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 DATE DATE MITTED AMOUNT DUE CHECKED <br /> R <br /> AMOUNT <br /> FEE A1.4 hzLr <br /> LESS / <br /> PRORATION J <br /> PLUS V ry <br /> PENALTY 6 <br /> OTHER - <br /> OTHER <br /> Received by Xate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> • APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />