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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable; Revocable, and Suspendable) SEPTAGE <br /> --'= ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of a San Joaquin Local Health District <br /> yBusiness Name (DBA)T � �r � '. j Address � � <br /> z Owner Address <br /> .9 <br /> Firm Partners, Addresses and Telephone Numbers a <br /> CL <br /> Business Telephone No. Emergency Telephone No <br /> Contractor Licence No. 1 <br /> L Applicants Name (Print) I +tle T - y 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. CRL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. z { <br /> 1 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 rn <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored r �� <br /> 3. ❑ PERCOLATION TEST <br /> � l <br /> R.S.or R.C.E.Name R.S:or R.C.E:No.' <br /> Test cation <br /> Test Date/Time 1 <br /> 4. 015,$ANITATION PERMIT <br /> .Job.-Address/Location �• <br /> Owner_ <br /> Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT"' ElPACKAGE PLANT <br /> WPERMANENT - ❑ TEMPORARY NEW 11REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 '` r <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 /> l Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant CapacityNo, 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/Mo. <br /> iF <br /> Home owneroriicensed anent'ssignature cer:4fiesfhef©Ilowing'"I certify that in thy;-cries--.,-nce 0;the wn,k icr;a?;ich this permit i5 issued,.)shall rotemplay any person <br /> in-suf.t'r manner aS 10 tiecor^,0 subj;ecl to wg rkrnr n'S conTensaliNi ' <br /> Conttsctor's hiring or ,uG-ron;rac ting �igra:,;ra certifies tie 10110%•,inq: 1 Certify it the performance et the work for which this permit is issued,I shall <br /> i employ persons subject to viorkman's compensation laws of Calilornii;.'" <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, a les and regulatio of the San aquin Lo Healh District. "tr <br /> � I <br /> - 'APPLICANT'S SIGNATURE X <br /> \0 <br /> F R DEPARTMENT USE ONLY. <br /> Fee Is Due: 11 ANNUALLY C1PER-:UNIT ❑ PER SITE ElEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> j - - REMIT <br /> BASE i BILLING , REMITTANCE - AMOUNT DUE CHECKED <br /> EXPLANATION. <br /> .,. - DATE t DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> ' PRORATION ¢ <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER. <br /> OTHER <br /> Received by r i -Date .Receipt No. w-*�+g^ Perm No. -t .Issu nce a Mailed Delivered .fi. <br /> I <br /> APPLICANT ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES" ` "'°"' 1601 E.NAZEL'TON .,P.O.Box 2009 'STOCKTON,CA 95201 <br />