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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 <br /> LIQUID WASTE <br /> Application is hereby made to carry on burliness in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name ( ) Address /� �.c�,, 4 <br /> a Owner Address _L�ik. Q� h V`�_--�. ��/V /5Z�s <br /> Firm Partners, Addresses and Telephone Nuers <br /> aBusiness Telephone No. m O Emergency Telephone No. <br /> 7Z5 0 12 <br /> Contractor Licence No. ple <br /> C; CIO <br /> L Applicants Name (Print) *JAL- Title 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 Chemical Toilets Stored <br /> 3. PERCOLATION TE0 <br /> R.S. or R.C.E. Name 0 t1At— wTLzwM,nom R.S. or R E. No. PCs )(06 <br /> Test Location 64U d AP /000 5. O ALL Test ❑ate/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 <br /> 5. ❑ 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 /> Homeowner orfiewitsod agent's signtliture certifies lthe fottowfng:"I certify that in the performance of the work far which this permit is issued,t shah not employ any person <br /> in such manner as to become Subject to workmal compensation taws of Ca!Vi 4 <br /> Cenumtw's fill or suy.00ntracting skrim ilte cerGiios the fotlowiuy 'I certify that in the perforMaliCe of the work fat which this permit Is issued,t shall <br /> empf y persons subject to workman s compensation laws of Calitortl <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 rules an gulations of a/San oa ui 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 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE�/ DATEfy� REMITTED AMOUNT <br /> FEE SQ�0 .0 <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receiv 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.Boz 2009 STOCKTON,CA 95201 — <br />