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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> r <br /> Application is r ade to cry o usi ss in the jurisdictional area of theme�Joaquin �al <br /> LocatDistrict <br /> Business Na DBA Address <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and T IP,phone Numbers <br /> Q, <br /> Business Telephone No. (j L Emergency Telephone No. <br /> Contractor Licence No. Xloez <br /> eS�Applicants Name (Print) ,_ Title Date1 01 <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.� fl f t <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. XSANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPO ,RE-LEACHING FIELD EPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 0 NEW W—REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 li <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 /> Home owner air licensed agent's signature certifier the foliawing:"I certify_tt1 at'l ntlleperlormance of the work for which this permit is issued,I shall not employ any person <br /> in such manner as to become subject to wcrrosan's <br /> Contractor's hiring or :ub-contracting z,;natvse �IeriGrn ,%- :.x•c%:, e2 i;,y t :;`,in It performance cf the work for wlFie!i ttiis pi mit is issued.I shall <br /> empioy per50Fls Subject to work.naTi'S compensa'Li0I;lav=s 0i'iafli:imi&.­ <br /> I hereby certify that I have pre ared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and ula i ns f the San Joaq Loca ealth District. <br /> APPLICANT'S SIGNATURE X D <br /> FOR DEPARTMENT US ONLY �YJ1 <br /> u� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receive8 By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issua ce Date Malted Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />