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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 /> Applicationi eb ade to a on usi ess in the jurisdictional area of the San oaquin Local Health-0 1 <br /> mBusiness Name ( A) Add ss�l�/� <br /> z OwnerAddress <br /> a <br /> J Firm Partners, Addresses and Tei p one um ers <br /> aBusiness Telephone No. ` Emergency Telephone No. , <br /> Contractor Licence No. C r <br /> L Applicants Name(Print) Titled - Date ^h <br /> Please check Applicable Category (1-7) and Fill in the Required Information +�V <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For Juiy 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) 1 <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 = fa <br /> 4. SANITATION PERMIT <br /> Job A dress/Locatio n ® /t <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL9-LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT - 9 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR 4AIOTHER <br /> 5. Cl CHEMICAL TOILETS For July 1, -June 30, 19 `644h4. AVN 'h► `Ef /�, <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1, -June 3.0, 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 /> #Ione owner ort;censod agenYsaignature certifiaxt he following."I cert ifylhat in the performance of the work far whfch this rCrmi t Is l s3uad,19h 311 n�1 <br /> in such manner as to become subject to workman s compensation laws of California" <br /> Contractor's p;ri $g or cub-contractilho signature .certifies the following; "f certify that in the performance of the work for which.h'3 rcrrAM I9 i"3u~1,16hnjl <br /> employ persons subject to workmans compensation laws of California." <br /> I hereby certify that I have pr ed this pplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and reg tions of a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X (�% <br /> FOR <br /> DEUART ENT USE QNLY r"C� <br /> Fee Is Due: LJ ANNUALLY ❑ PEFUNIT ❑ P u LEACH January 1 8, --mvved 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 c� <br /> LESS7i 6:k <br /> PRORATION <br /> PLUS r <br /> PENALTY ,7 IL—. <br /> OTHER AZ k"RG <br /> OTHER <br /> X93,59a Lo 2-a- <br /> Received by Date Receipt No. Permit No Issu rice Date I mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />