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:r • (For Non-Transferable, Revocable,and Suspendable) SEPTAGF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San oaquin Local Health District <br /> v;Business Name (DBA) >' Address <br /> Owner -. OQA1191n� AddressrJ — - <br /> Firm Partners, Addresses and Telephonem rs —-- <br /> IL <br /> 3. Business Telephone No. S1�-� �r ,/ 7 Emergency Telephone No.It <br /> Contractor Licence No. - --- <br /> L Applicants Name (Print) TitleDate -- <br /> Please check Applicable Category(1- )and Fill in the R utred 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 Location Test Date/Time - <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Locatioon - <br /> Owner .7j d��!L r R A Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ElSEEPAGE PIT ❑ PAC KAG ANT <br /> CJ <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction - Disposal Site_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 /> t t: ❑ DRY CLEANING,Chemicals Used/Amount/Mo. -- - <br /> Home owneroriicenw-d aEea!'a signature aartiffes tSs following:"I crrflfy that En the perlortnanceo1 thework for which this permit is issued I shall not employ any pet <br /> in such manner as is�rx; ;cuiect to <br /> Contractor's hiring w sub-c-,nirert:,v cigi;vwre cvrthics 1hE to,iowinu. 1 cLridv that in the performance of ihe,cork fur which this permit is issued,I shall <br /> employ persons suJ;et,.(. .r t),::3,i s m�uv,abu.l law>uI CStil ;niJ" <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 and regu13H6n�he San oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -- - t- `� - <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> _ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE +� <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> F� <br /> OTHER <br /> Received by Date Receipt No. Permit No. issuilince Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.eor 2009 ,STOCKTON,CA 95201 <br />