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Applications WilI"9gIrr—ocessed When Submitted Properly Completed.BeSureTo signTheAppucauan. <br /> APPLICATION <br /> r (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicat' n is hereby ni to carry on business in the jurisdictional area of the San JoaqujD Lci Health Dis 'ct <br /> rBusiness NMpe (DBA) Address Ir 0 • �r 1 CT <br /> z Owner D Address <br /> 4 <br /> Firm Partners, Addresses an Tel hone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) I Title W Date �1 ! <br /> Please check Applicable Category(1-7)and Fill in the Required Information '+ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For Juiy 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. W CAL. License No. CAL. License Renewal No. <br /> Capacity Gai., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> { <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Tet Location Test Date/Time <br /> /4. )SANITATION PERMI <br /> Job Addr /Location 2,40dl <br /> �Owner Address <br /> , L'SEPTIC TANK ❑ CESSPOOL BLEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARY _*Ek-KEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) — <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. j <br /> Fiume ownerorlicensed agent'sniqicerti{i�!!the following:"I certify that in the performance of the work forwhichthis permit is issued,I shall not employ any iin such manner as to becomer: <br /> Subject to o ii�uii s eotrilensation laws of Caiifor ia.' <br /> Contractor's hiring Or ,ub-CDntrai ing signature certifies thr, faliowing: 1 certify that in t`te performance of the work for which this permit is issued,I at :I <br /> employ persons subject to workman's compensatioti taws of Catilurnia." <br /> I hereby certify that I have pre aced thip applicai n and that the work will be done in accordance with San Joaquin County <br /> ordinani state laws, and w es nd r ulatio f hie San Joa in Ocal Health District. <br /> APPLICANT'S SIGNATURE X o 7 <br /> b- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 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 /> OO <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY AJ <br /> OTHER 1 <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuarli 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 />