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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 /> r LIQUID WASTE <br /> Application is eb made carry on b siness in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address_���35' >��� <br /> a Owner ��� 4)—dr-1 � /�,,. Address <br /> J Firm Partners, Addresses and Telephone Number <br /> MBusiness Telephone No. Emergency Telephone No. ' V <br /> Contractor Licence No. <br /> L Applicants Name (Print) /-i Title Date <br /> .41 <br /> . I <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) q � <br /> For July 1, June 30, 19 Disposal Sites V" <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 I I <br /> Job Address/ cation <br /> OwnerF Address <br /> AEPTIC TANK CESSPOOL 091 /LEACHING FIELD P<SEEPAGE PIT ❑ PACKAGE PLANT <br /> �PLPERMANENT " 1:1TEMPORARY NEW E3REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July.1, -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. <br /> Home owneror licensed fallowing:"I certify th?.t in thope,normanre of tfs-work for which this permit is issued,f shah not em7shall <br /> in such manner as to became subjectto warkman's compensat;otr laws of California ' <br /> Contractor's hiring or sub-contracting signature eartifias ;he follwmns: 1 certify that in the periormanceat the work for which this permit is issued,I t <br /> -employ persons subject ID workman's compensation laws of Golflornia." <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 lations of heSa aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACHi ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> _ REMIT <br /> BILLING REMITTANCE $ <br /> BASE � EXPLANATION i - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT f <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER l <br /> OTHER <br /> r" <br /> Received by Date 'Receipt No. Permit No. Is uance D to r Mailed Defivered _ <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES {,1�6�0,1�E�.HAZELTO JN AVE„P.O.Box 2009 'STOCKTON,CA 95261 <br /> 1( _ },,- ,,k-4 --, /' � r <br />