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Applications Will Be Processed When Submitted Properly Completed. BeSure To Sign TheApplication. <br /> APPLICATION <br /> - (For Non-Transferable, Revocable,and Suspendable) 1 <br /> � SEPTAGE <br /> .'ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicationi he by made <br /> ame (DBA) to carry on business in the jurisdictional area oft San aquin Local Health District <br /> ,„Business N + q- il9 -, C Address <br /> z Owner Address - <br /> a <br /> Firm Partners,Addresses and Telephone Numbers <br /> m Business Telephone No. 7 Emergency Telephone No, <br /> Contractor Licence No. nIt <br /> Applicants Name (Print) Title rl< b Date <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 /> 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. Name R.S. or R.C.E. No. <br /> TesLycation Test Date/Time <br /> 4. tK.SANITATION PERMIT <br /> Job Address/Location W <br /> O ner 1--.5 aa,w_ �;4A-Ah -� Address <br /> SEPTIC TANK ❑ CESSPOOL 01 LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r L <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 No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE! ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft... <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Ma. <br /> Home owner or llceneed agent's SignatUrRCPrte=issTlfe`allowing:1 certify thm infhe,er`ermance of the work for iwhEch this permit is issued,t stall not em piny any person <br /> in such manner as to become subject to workman'E compensation laws of California_" <br /> Contractor's hiring or Nub-contracting signatore certifies the foUovAna: "t certify that in the performance of the work far which this permit is issued.I shall <br /> employ persons Subfect to workmalt's compembon taws of Califomie <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, and res and regulatio of the S uin Lo ealth' istrict. " <br /> APPLICANT'S SIGNATURE X - <br /> .- 0 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Ju$y 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ C <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE D <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - - <br /> t <br /> OTHER <br /> OTHER + <br /> ♦ t l <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 95201 <br />