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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 business in the jurisdictional area of the San Joaquin Local Health District: <br /> UF) Business Name (DBA) Address <br /> z Owner Address <br /> J Firm Partners, Addresses and Te ephone Number <br /> aBusiness Telephone No.. - Emergency Telephone No. <br /> -j Contractor Licence No. <br /> L Applicants Name (Print) _ 1 <br /> a Tikle� Date � ��- <br /> Please check Applicable Category (1-7)and Fill in the Required Information t: r <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. �il SANITATION PERMIT <br /> Job Address/Location Aj <br /> Owner_7;'­­4e f r ig Address 4;7� <br /> ❑ SEPTIC TANK. < ❑ CESSPOOL" LEACHING FIELD 11T <br /> SEEPAGE PI_ ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑'NEW REPAIR <br /> ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> r <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. 7 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ffameownerortjcanaedagent's signaturecertlfreathefollowirtg:"Icrrtifyth-i<<nthpenr-- r.r !!,p ,r.Y!tnr4.h ' 'his permit is issued,IShall not employ any l,, Tal � <br /> In such manner as to become sul?ject to vjarkmarf�>snm en;,�".jr.' .P %il: <br /> Contrft-tot's hiring or Sub-CUntractfng Signal Ire cor:His,_ .a'- „ni;1,L, , a ,3:';;', -,„ri;rC:jisl li;�r;Li°,C i iiTe workfor which this permit is iSSued,I Stlai, r <br /> employ persons subject to workman's compensation laws of Galijornia:•. <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 regulations of the San Joaquin 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 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE r <br /> LESS <br /> PRORATION <br /> pf <br /> PLUS D <br /> PENALTY <br /> OTHER - <br /> OTHER _ <br /> Received by Date z Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES 1601 E.HAZELTON AVE.,P.O.Box 2009' STOCKTON,CA 35201 <br />