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in4 S � }� <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure o Sign a <br /> APPLICATION <br /> 3 (For Non-Transterable,'Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio ' hereby to arty n business in the jurisdictional area of the Sa oquirybocaLHealth District <br /> H Business Name (DBA} da _Address ���� <br /> a Owner— <br /> Address <br /> wa x• <br /> J Firm Partners, Addresses and Telephone Num0r$ <br /> CL Business Telephone No.. G- Emergency Telephone No. <br /> �. , <br /> a � ., <br /> �Contractor Licenpe No. b pate t <br /> LApplicanis Name (Print) �� Title .W <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, <br /> June 30, 19Disposa1 Sites <br /> Description(Make/Yr.,Color) CAL. License Renewal No. Q� <br /> Serial No, CAL. License No. 1 <br /> Capacity Gal.,Weights &Measures-No, <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> r <br /> No. of Vehicles Stored - <br /> No. of Chemical Toilets Stored , <br /> 3. ❑ PERCOLATION:TEST <br /> • R.S. or R.G.E. No. <br /> R.S.or R.C.E. Name <br /> Test Location est ate/Time <br /> 4. ❑ SANITATION PERMIT 4 <br /> Job Address/Lo <br /> Owner i ddress <br /> ❑ SEPTIC TA K ❑ CE PO L 'LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT W <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction - Disposal Site \� <br /> No. of Units Equipment Storage/Cleaning Locations} <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name - <br /> s <br /> Plant Location ` <br /> Plant Capacity t No. Units Served ^B <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> . ❑ More Than 1,000 Sq. Ft. , <br /> 1 000 S . Ft, <br /> ❑ Less Than q <br />� SIZE: - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> tiamsarrrm.orlicenaedngent'se;gnafh+r+sceetifiestl�efoNowin9;:1 thatint!ePe oimanCiof#heW"*ferWfHt*,MiSempt/YAnywson <br /> in such manner as to become subject to workman's compensatian taws at n tforltia <br /> '1 Cert <br /> Corwsators or a1t4.ctr►p6lctl9 � codito the !01111 vtrly ifytthatitrtfto_petfcr npeetlhe+Aarl7cfor wtlicflthis permit isissued.lsttali <br /> employ persm subj tt to workman'scompensallon taws of Falft"la" I <br />' is ap licatiori%Lnd that the work w' be done in accordance with San Joaquin County <br /> I hereby certify that I have pre red <br /> ordinances, state laws, and ruI an eggl ons of San J u n Loc e Ith District. <br /> APPLICANT'S SIGNATURE X _- = <br /> ion FOR DEPARTMENT USE ONLY <br /> c <br /> ❑ PER UNIT, ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv REMIT <br /> 31 <br /> Fee IS Due: 1:1 ANNUALLY <br /> BASE EXPLANATION BILLING' REMITTANCE $ AMOUNT DUE CHECKED <br /> g <br /> .DATE. -DATE., .REMITTED -AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> - <br /> OTHER <br /> OTHER <br /> T"" 1 <br /> Mailed Delivered <br /> Received by , <br /> Date Receipt No. Permit No. issuance ate <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 85201 - <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMITISERVICES ' <br />