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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) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic ' n is gereby ma a to carry o busi Ss. the risdictional area of th a Joa In Local Health Distri I <br /> F Busine ame (DBA Address , , <br /> aOwne Address - <br /> J Firm Partners, Addresses and Telepho Numbers <br /> a. Business Telephone No. 9s_ Emergency Telephone No. 7+ <br /> 1 Contractor Licence No. ,2-Z QP <br /> Applicants Name(Print) Title Date <br /> Please check Applice.ble.Cate ry (1-7)and Fill in the equired Information W <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For JUIy 1, June 30, 19 V Disposal Sites _....... <br /> Description(Make/Yr.;Color) * f <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. t <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD '"' <br /> Al <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ti --- <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test L� tion Test Date/Time <br /> 4. u•SA"NITATION PERMIT <br /> Job Ad <br /> Owner Address ^Y <br /> © SEPTIC TANK—_D,CESSP _ El LEACHING FIELD SEEPAGE PIT PACKAGE PLANT! _ }w <br /> ,,, *E / <br /> ❑�RMANENT C] TEMPORARY 1:1 NEW-- `- — ��7-TIEPAIR_ ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �` 1 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) *� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19A_—' <br /> Operator Name I ) - — Where Certified <br /> Plant Location ) f <br /> Plant Capacity No. Units Served ( ° <br /> 7. ❑ L"AUNDRY For July 1, -June 30, 19 <br /> SIZE: 4.10 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. i <br /> ❑ DRY..CLEANING, Chemicals Used/Amount/Mo. <br /> ' <br /> Hbrneownerarticensedagent's signature ee"Mesthefriiowing;'Icertify that in the performance of hewo�icfarwhichthispertnitisissued,IshalInoternployanyperson <br /> 1n'sHrh manner as to became subject to workman's conlpcnsation la"rs�f Catii�+,; " <br /> Conlracto!s Miring or sub-contracting signavurc certifies thv^'o93vrvi%: 'i Ger:if that iR the Performance of the work for which this peimlt IS ISSUCd,f Shalt <br /> employ persons subject to workman's corrpensalio iaA's of Ca;;tu; f <br /> ,.--1 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, d rules and regula ' ns of the San Joaquin Locdl Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPAOMENT USE ONLY <br /> 'Fee IS Due:,[],ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &-Received By January 31 ,❑duly 1 &Received By July 31 <br /> _ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED._ r/ AMOU <br /> i '.FEE t <br /> LESS PRORATION--+— <br /> PLUS <br /> RORATION-+PLUS all <br /> PENALTY <br /> OTHER "00 01 <br /> OTHER <br /> C�_ v <br /> Received by Date Receipt No. Permit No t Issua ce 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 />