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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 /> Applica Ion is ir�e�by�m�ade o ar on business in the jurisdictional area of t San Joaquin ocal Health. istric�t ('� p <br /> rn Business Name (DBA)��` ^ a� Address ®^ k_ `S Lt� �fi�2iQ 1 <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. � ® �D`� Emergency Telephone No. <br /> -i Contractor Licence No. Z <br /> L Applicants Name(Print) S Title Kk Date 'S—4 <br /> Please check Applicable Category(1-7)and FIN 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 /> T t ocation Test Date/Time <br /> 41 SANITATION PERMIT <br /> Job Addresss//Loocation 30 0('o I ZS �S5©rV JcP• 2AJ I Sr'Q0 o iPr 1'1_146.1/ <br /> Owner—P—OU . M- L1_=AC-"Xf,SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑.SEEPAGE PIT ❑ PACKAGE PLANT CNP <br /> XPERMANENT P TEMPORARY ❑ NEW XREPAIR - ❑ 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 owner or licensed agent's signature certi aevtl--following:1certifyythatintheperformanceoftheworkforwhichthispermitisissued,Ishallnotemployanyperson <br /> insuch manner asto becomes0jectto workman's coaipellsation fauns of California" <br /> Contractors (siring or sub-contracting .ign82ure car6fies.t1w following: "I certify that in the performance of the work for which this permit is issued,l shall <br /> employ persons subject to workman's comperisatlon laws of Caiifornia." <br /> I hereby certify that I have pared this application and that the wor ' `be done in accordance with San Joaquin County �► <br /> ordinances,state laws, r gulat' of the S aqui ocal alth 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 /> BILLING ITTANCE $ <br /> _.BASE EXPLANATION ... AMOUNT DUE CHECKED <br /> DA DATE REMITTED AMOUNT <br /> FEE N. <br /> a0 <br /> LESS <br /> PRORATION s ?' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O <br /> Received by Date Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Isiril E.HAZELTON AVS.,P.O.Box 2009. STOCKTON,CA 95201 <br />