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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 carryon business' the risdictional area of the <br /> an Joaquin Local Health District <br /> xy Business Name (D 112,d%mill Addre M0. <br /> z Owner +� Address 19 2 <br /> a <br /> Firm Partners, Addresses and Telephone Numbers Al <br /> aBusiness Telephone No. Oq 34- 6`U Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) yt rinwl tLCl�lQl ttiElEle 1 rM n— Title ,F 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. f Chemical Toilets Stored <br /> 3. PERCOLATION TEST S �l �` <br /> R.S. or R.C.E. Name S. or R.C.E. No. <br /> Test Location - Test Date/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 C <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. I I <br /> Homeowner or licensed agenfssignature eer!?iesthe fotlowing:"I certify that In Me performance of the work forwhich this permit Is Issued,I shall not empl iyanyop— <br /> in such mariner as to become subject to workman's compensat"cn taws of Calfforrio,' <br /> Contractor's hirin or sub-contracting signature eertmies I'm foaovving: I certify that s;., <br /> in the performance of the work for which this permit is isct: ',I <br /> e�{11ay persons subject to workman's compensation laws of California." <br /> I hereby certify that I have prepared this applicati n and tha he work will be done in accordance with San Joaquin CO my <br /> ordinances, state laws, an I regu a quin Lo ca Health D' t *ct. j <br /> APPLICANT'S SIGNATURE X 0 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 y 31 <br /> EMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE C CKED <br /> DATE DATE REMITTED A PUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> AMPYFfedWrved by Date Receipt No. ermit 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 />