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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> }` APPLICATION <br /> + or Nan-Transferable;Revocable',`and SuspendaL,,, SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> - LIQUI0 WASTE t <br /> Application is hereby made to carryon business in-the jurisdictional area of the San Joaquin Local Health District <br /> rn Business me (DBA) Address j <br /> aOwner Address <br /> J Firm Partners, Addresses andTelephone Numbers <br /> aBusiness-Telephone No. F.t.3 / Emergency Telephone.No. <br /> 3 Contractor Licence No. - <br /> iuGtle¢C '—ULLl1V� Date/�-/�`�• <br /> �Applicants Name{Print) -Ti- <br /> _ s , � �� <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. 13 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,'--- June30,'19T- w 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. 14 PERCOLATION TEST — ---- <br /> Ir � <br /> R.S. or R.C.E. Nam R.S. or R.C..E. No. <br /> Test Location /97 zw, Test Date/Time <br /> 4. 1:1SANITATION PERMIT Ua`= <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK •❑ CESSPOOL ❑ LEACHING FIELD -❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT © TEMPORARY ❑ NEW ❑ REPAIR ❑ 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 s No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ' ­�,�,, _\ <br /> SIZE: El Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.-Ff. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Horheawnerorrcensedagent's signature".t6finsthefoHowfng:"I certifythal;P"t,etscrtnr,nancecfthe�v6rlsforvA0thispermitisissued,Ishallnotemployanypemnr <br /> in sueh manner as to become sub,iKf to L;i:,T:i{as <br /> Contractor's hiring or sub-1:0zlgoatum eesIK;es Via fuilu%Qdn9. -i earthy that iii the per ormsnce of tha work for which This permit is issued,I shall <br /> employ persons sub)ect to workman's compensatiuri taws of California." + <br /> I hereby certify that I have prepared this application and that the work will_.be done in accordance with San Joaquin County <br /> ordinances, state laws, rules and regulations o n.oaquin Local Health District. <br /> i <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE —[YEACH — ❑ January 1 &Received By January_31. _ ❑ July 1 &Received By July 31 <br /> REMIT <br /> F BASE EXPLANATION �,,.BILLFNG "-� REMITTANCE"ft'ti` ., $ AMOUNTDUE CHECKED <br /> DATE . --�'DATEr---...REMITTED-•- . w - ---- -- AMOUNT <br /> FEE r D0 , 1:/ <br /> LESS <br /> PRORATION 14, <br /> - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> CY <br /> Received by Date r Receipt No. Permit No. Issuance Date Mailed Delivered 4 <br /> -; APPLICANT.-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:aac 2009 STOCKTON,CA 95201 <br />