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�..�: ✓ <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION } <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> G, LIQUID WASTE <br /> Application i feby�made to car ouhusiness' the j nsdi ional area of the Sa oaquin Local Heal D' ict <br /> y Business (D <br /> .A dress <br /> a Owner <br /> ddress <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. � Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Title- Date <br /> L Applicants Name (Print) ! <br /> Please check'Applicable'`Ca go 1-7)and Fill In the Req ired Information n: <br /> 1. ❑ PUMPER VEHICLE P IT REGISTRATION (FOR EACH VEHICLE) i <br /> For July.1, June 30,'19 Disposal Sites 1 <br /> Description(Make/Yr., Color) CAL. License License Renewal No. <br /> Serial No. CAL. License No., l <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. ❑ PERCOLATION TEST <br /> R.S. or R :E . Name R.S. or R.C.E. No. <br /> Test cation Test Date/Time- <br /> 4. 0 SANITATION PERMIT <br /> Job Ad ss/Location <br /> d <br /> O Address . r <br /> ❑PACKAGE PLANT <br /> EPTIC TAN 11 CESSPOOL LE��ING FIELD SEEPAGE PIT <br /> OTHER <br /> ❑ PERMANENT ❑ TEMPORARY i�NEW El REPAIR Y "J <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 30,9 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July.1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq`, Ft., ❑ More Than 1,000 Sq. Ft. <br /> l ❑ DRY CLEANING, Chemicals UsedlAmount/Mo. <br /> Homeownerorlicensed agent's signature certifiesthefollowing:"t certify that in the performance of-the work forwhich this permit is issued,I shall not employ any pars, <br /> in such manner as to become subject to workman s compensation laws of California." <br /> Contractor's hiring.or sub-contracting signature certifies the following: 1 certify that in the performarce of fbe work for which'thfs permit is issue6,I sha':l <br /> employ persons subject to workmarts compensation laws of Calitotnia." <br /> I hereby certify that I have prep d this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul d regula 0 e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE.X <br /> FOR DEPARTMENT USE ONLY <br /> :" �$ Fee;15'DUe: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Yom°° REMIT <br /> BILLING REMITTANCE '$ AMOUNT DUE CHECKED <br /> r �, BASE EXPLANATION DATE DATE REMITTED. AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> t PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. ermtit No. - sine Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL'HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 95201 <br />