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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TneApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> y ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio her by m e to c rryon b fines in�t'�'e jurisdictional area of the Joaq Local He Ith Di ict <br /> N Busines (DBA) SZ �f Addre 's <br /> aOwnerT l� �� F^ Address <br /> J Firm Partners, Addresses and�T/lephone Numbers - <br /> CL <br /> umbers <br /> aBusiness Telephone No. �._ '3y'33 Emergency Telephone No <br /> -Contractor Licence No. 7«L <br /> L Applicants Name(Print) G Tille <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 /> Equipmen)Parking Address. <br /> 2. ❑ PUMPER YARD <br /> For July 1, Y June 30, 19' -I <br /> No. of Vehicles Sto;ed <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 /J <br /> 4. U-SANITATION PERMIT �v <br /> Job Address/L ation <br /> Owner Address— SAP&4 <br /> ❑ SEPTI TANK 1R CESSPO L- B'1 CHING FIELD 0-SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT TEMPORARY ❑ NEW 11--REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site n <br /> No. of Units Equipment Storage/Cleaning Location(s) '" <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> �r <br /> Operator Name Where Certified <br /> Plant Location — <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July i, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More':Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/AmounVMo,r <br /> Home owner or Ircanaed agent'Iralpnature cartitlea theiotlowin4t:"l dertify that in the performance of The work f or w hick this permit is issued,I shall not am ploy any person <br /> in such manner as to beams sub*t to workman's compensation IxN s.if falilo;nes: <br /> Contractor's kiting or sub-contractinq signaturo certMes :he following; TCerlily that in the per#ornlance of the wGrk for which this permit:s Lsued,I shall <br /> employ persons supjsct to workman's compeasatian laws 1If California _ <br /> I hereby certify that I have prepared this-a ratio and that t-h ork�-wilt be done in-accordance with San Joaquin County <br /> ordinances, state laws, an and ul o o he San Joaquin Local Health District.- <br /> APPLICANT'S SIGNATURE X r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT �❑ PER SITE ❑ EACH ❑ January 1 &Received Ry January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE c� S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY t <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is ante Mle Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Vox 2009 STOCKTON,CA 95201/ <br />