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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> A ,h i/�-3 �1f (For Non-Transferable,Revocable,and Suspendable) / SEPTAGE <br /> 1V U ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati n l h reb madejto cro�on.�b,,usine a jurisdictional area of San Joa ocaI H h D strict <br /> HBusiness Name (DBA) c � Address <br /> aOwner Address <br /> Firm Partners, Addresses an ;gh a Numbers <br /> IL <br /> Business Telephone No. (p{� Emergency Telephone No. �1 <br /> Contractor Licence No. —' <br /> Applicants Name (Print) Title Date <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. <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 PER <br /> Job Address/LocationX <br /> Owner ^ )DA" �- Address <br /> ❑ SEPTIC TAW ❑ CESSPOOL LEACHING FIELD ❑ 'SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ' ❑ TEMPORARY ❑ NEW 4KREPAIR OTHER <br /> 5. 11 CHEMICAL TOILETS For Jul 1,-June 30, 19 t <br /> Type Construction Disposal Site k Otter <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..Chemicat"sed/Amount/Mo <br /> "ermeownerorlteensedagent'sstgnaturecertifie,athefnflov.,:F IC,e0 ,!hM;nIh onA•fnrm rrF P. th j„rr6,f-,. �!1 'hif,pprr0isi>suAd'is .ls" 1lnot�rplcyattyaersor 0 <br /> 1 <br /> tot's hiring or sub cuntr.aC ,n,, _! _ � [._ +...i.in.u..r t.,y .S.Cu,,,ulu r(Ol tG. l&fJ, s tit Inn Yvui k foo oiroch i Ls pel hilt i;:,;6ued,I Shall d <br /> employ persons subject to workman s compensatiuri lay.s ut Lai,iu"Ila" C <br /> 0 <br /> I hereby certify that I have prepared this appl' atio and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and fui regu s o an Jo quin 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 /> BILLING RE ITTANCE $ REMIT <br /> BASE EXPLANATION M AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3S3o �� gl <br /> Received by Date Receipt No. Permit No. I. Issua ce to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />