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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i relay made to c try on usi in the ju i Tonal area of the Sanquin Local Health Dista <br /> rn Business Name ( A) ddress <br /> aOwner Address - <br /> J Firm Partners, Addresses an e e hone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Applicants Name (Print) Title Date a �� <br /> Please ch ck Applicable ategory (1-7)and Fill in the Requi d In ormation ) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. x <br /> Capacity ' '- Gal.,Weights &Measures No. V" <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 ame R.S. or R.C.E. No. <br /> Test L Ion Test Date/Time <br /> 4. SANITATION PERMIT <br /> i <br /> Job Address/-location � <br /> Owns Address <br /> TIC T K ❑ CESSPO LEACHING FIELD SEEPAGE PIT PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 CA <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 11PACKAGE TREATMENT PLANT For July 1, -June 30, <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served I. `L <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ MoreTh n 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/M, <br /> . <br /> Home owner'rHcensedogerrt'ssiynatureeertffieat91'IIowjng:"Icert�That inthe performance ofttrewart WwhichWSPermitisis5u l,tshatlnotemployanyperson <br /> in Such manner as to bKoma subject to workman's campensatiotl laws otGa itornia.' <br /> Contractor's hiring of suib-contraeting signeterre certifies the following: _.l cettity that in the perf"mance of the work for which this permit is issued,t shall <br /> employ persons subject to workmans compensation laws of California." <br /> 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, and rul s and regulations o an Joaquin Local He th 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> J p !a., <br /> FEE ` <br /> LESS Cf J <br /> PRORATION 11 <br /> PLUS <br /> PENALTY <br /> t< <br /> OTHER <br /> OTHER <br /> d <br /> Received by Date Receipt No. Permit No, Iss anc -Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />