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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION �. <br /> ti <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> V LIQUID WASTE <br /> Application is eby_made to c on i ss in the jurisdictional area of the San Joaquin Local Health District C10 Business Name (D ' Address <br /> z Owner. - Address• I <br /> ¢ _ <br /> Firm Partners, Addresses and Telephone Numbers <br /> E. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title. Date <br /> Please check Applicable Category (1-7)and Fill in.the Required Information 4 _ <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 /V <br /> Job Address/Location <br /> Owner Address <br /> yyy 11 <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIE SEEPAGE PITj� ❑ PACKAGE PLANT10� _ 1 <br /> © PERMANENT ❑ TEMPORARY NEW LJ REPAIR ❑ OTHER 4 <br /> 5. 1:1 CHEMICAL TOILETS For July1,-June 30, 19 <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. �I <br /> Home ownernrticenseclsger•,'aser�n:t ree�rtt 9eRt"sfc!to1Zh :"Icerfi(ysi;.=! n{." ancaofthe work lorwhicythispermitisissued,fshallnotetployanyperson--z <br /> in such manner as to becorrle S1111ject to iv7rF,rt ,"'s rou:fsnsatinn i,;rnN,of Catiicrli:: <br /> Contractor's hiring or verti!ies Shn fotiowinq: "I certify that in the performance of the work for which this permit is issued.I shall ll— <br /> employ persons subject to workmai;s co:npensa;ion laws of calif imia." j <br /> I hereby certify that I have prepared this ap lication and that the work will be done in' accordance with San Joaquin County <br /> ordinances, state laws, and r sand regula ons of a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 CHECK <br /> DATE DATE REMITTED A <br /> FEE bKk <br /> � D•<. _._. <br /> LESS ; <br /> PRORATION ' <br /> PLUS ( M <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date - Receipt No.. Permit No. t `'Iss ante Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES is( E.HAZELTO4 AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />