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pfl r_.ations Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApprlcauon. <br /> ii - Il APPLICATION i <br /> 5als'. 7='+� (For Non-Transferable,Revocable,'and Suspendable) SEPAGE w ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE - <br /> �r5 <br />/FBLisiness <br /> Application is hereby made to carry busine in the j,prisdjctional area of thein LuAddress �--o�Name (DBA) T• <br /> - ,.� <br /> 4'Owner . - Addr ss 3 <br /> 9 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No , <br /> -j Contractor Licence No. <br /> Applicants Name (Print) Title Date- r <br /> Please check Applicable Category.(1-7)and Fill in the Requited Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4 <br /> For July 1, -June 30,-19--- Disposal Sites 4 <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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.No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> A-SANITATION PERMIT �,Z <br /> Job Address/Locati n <br /> Owner Address <br /> 'SEPTIC TANK " ❑ CESSPOOL LEACHING FIELD ❑ S'EE PAGE PIT PACKAGE PLANT <br /> 11PERMANENT 13TEMPORARY ❑ NEW ❑ REPAIR 13 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site I <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July f -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity <br /> ' 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 /> Prr>lneownwerrrctnmdagent•eaignalurecetitliteatlMlatowtnp:'t t iRthtt{ armanceofthe Work forwtlitdrthispern+itisissued.fShall notempiayanyperson <br /> in sU0 Manner as to becme subfWf o w tnlWs " ` <br /> Contractor`: t oe s p o"" mut tiler� -1 catity that in tfte perftmrica of the rrcrk for which this permit is issued.I shall <br /> employ persons t!f work=Ws compettsation tWAI9 wr CrafiMrnitL' <br /> I hereby certify that I have prepared this ap I" and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules a ns of the S o oval Health District. ¢ <br /> t�APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USEt By <br /> ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT _ ❑ PER SITE ElEACH 0 January i &Received By January 31 ❑ July t &ReceivedREMITuIy 31 <br /> t 1 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> tt J <br /> I FEE <br /> LESS <br /> PRORATION - -- <br /> PLUS <br /> PENALTY <br /> ' OTHER ^ <br /> OTHER <br /> Receive " Dat6 r Receipt No Permit No. Issuance ate Mailed Delivered <br /> APPLI At�}7RETUMN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 w l <br /> 3 6a�� <br />