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Applications*ill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> '= ENVIRONMENTAL HEALTH PERMIT SEPTAGE { <br /> LIQUID WASTE <br /> r AP-0ica ' is here me e# carry n bus'ness in e' risdi ional area of the S i a ul ocal Health District p <br /> y Busines ame (DBA) M Address �c �o 1 �bC�i r �_ t <br /> aOwner Address <br /> J Firm Partners, Addresses and Tele hone Numbe <br /> aBusiness Telephone No. Emergency Telephone No. <br /> j Contractor Licence No. �''� <br /> L Applicants Name (Print) hl Title L��, Date <br /> � <br /> "7)and Fill in the Required Information <br /> Please check Applicable C4W9Ory (" <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 �`M Disposal Sites --� <br /> Description(Make/Yr.,-Color) <br /> Q, r r <br /> Serial No., � CAL. License No. CAL. License Renewal No. <br /> T,Capacity- IGal., Weights &Measures No. <br /> ,Equipment Parking Address"', <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 �I <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name _ C R.S. or R.C.E. No. <br /> Test Location —�� <- Test Date/Time , <br /> 4. i�SANITATION PERMI ' <br /> Job Addre Location r <br /> f <br /> Owner "'~Address <br /> I❑SEPTIC TANK ❑ CESSP0001 ❑ LEACHING FIELD ❑ SEE AGE PIT ❑ PACKAGE PLANT <br /> gi'PERMANENT ❑ TEMPORARY ❑ NEW L'�'REPAIR �5 <br /> 5. ❑ CHEMICAL TOILETS For Jul`y 1, -June 30, 19 U'~- <br /> Type Construction Disposal Site <br /> No. of Units ,' Equipment Storage/Cleanin` g-L cation(s), <br /> B. 13 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name iM; - Where Certified - <br /> Plant Location <br /> Plant Capacity 1� No. Units Served, <br /> 7. ❑ LAUNDRY For July 1; -June�30, 19 �. <br /> SIZE- ❑ Less Than 1,000 Sq, Ft.,I ❑ More Than 1-,000 Sq:Ft. 5 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. � = <br /> ownerorRcensedagent's atg ture!certiftesttwfc�llawin�'"l certifyth^ `^thane ntmartrpofthe wotkfor wh4cAMispermitIsiss'^r"rhzk1ristemplo';anypersen <br /> such manner as to become subject to workman's compensation faw5 of Caffc <br /> ;;"otols hiring or sub-contreccing signature eerwies the toltowinw: I Leni,y that in the petformance oI tht work for wl:ici�t;:r ,,�i t:i;is issued;,':shall <br /> ploy persons Cl to workMatt'si`compensation laws of California." <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, rules and regal ions of the San Joaquin Local Health District. } <br /> ,I <br /> JV <br /> APPLICANT'S SIGNATURE. t <br /> I' FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY. ❑,PER-UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 r <br /> v1 <br /> w-BA�' ill BILLING REMITTANCE $ REMIT <br /> - <br /> SE J EXPLANATION AMOUNT DUE' CHECKED <br /> DATE DATE REMITTED L� AMOUNT <br /> FEE ' i S {fid` <br /> LESS 7I` I its <br /> PRORATION <br /> PLUS ill <br /> PENALTY <br /> OTHER <br /> OTHER ! <br /> I� <br /> Received by- Date i Receipt NoPermit No- 11suance Date Mailed- Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box_200$ STOCKTON,CA 9 2DI �� � <br />