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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) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatioi her y ma�t�orryo n the jurisdictional area of the a Loc Ith District <br /> ,n Business (DQA) Address _ <br /> aOwner ddress ��[[JJ <br /> Firm Partners, Addresses and Tel ph ne Nu be <br /> CL Business Telephone No. r/ Emergency Telephone No <br /> Contractor Licence No. lie Z4 1 <br /> L Applicants Name (Print) Title ate <br /> Please check Applicable Category (1-7)and Fill In the Required Information *„ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O� <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 YARDFor July 1, June 30, 19 <br /> No. of Vehicles Stored ## ' ► <br /> No. of Chemical Toilets Stored +. n <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name r4 '�r'" ti tib;► R.S. or R.C.E. No, <br /> Test Location Test Date/Time x <br /> 4. ❑ SANITATION PERMIT Q <br /> Job Address/Location <br /> Ower 4 Address r ' <br /> 9 SEPTIC TANK ❑ CESSPOOL 'LEACHING FIELD 'Q SEEPAGE PIT ❑ PACKAGE'PLANT.} 1 <br /> 15'PERMANENT ❑ TEMPORARY ❑—NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 w <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning.Location(s),.!- Af <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 7 4 <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/Mo. <br /> Hama owner or licensed agent's signaturecert'Mosthafollowing:"I certify that in the peffnrmance of the workfor which this permit is issued,l shall not employ any person <br /> it such mamier as to become subject to workman's compensation laws t1i Catifoi nia ' <br /> Contractor's hiring or sub-contracting signature certifies the totlowinw A certify thai in t"performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's comperisdtion laws of Caiiiurnia." <br /> I hereby certify that I have prepared this plic 'on and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rules and re on of the San Joaquin Local Health District. —.r- <br /> APPLICANT'S SIGNATUR <br /> If <br /> FOR DEPARTMENT USE ONLY <br /> YJgg f r <br /> Fee IS Due: ElANNUALLY ❑ PER UNIT ❑ PEIR SITE [ ❑ EACH El January 1 &Receivedf By January 31 ❑ Ju€y 1 &Received By July 31 <br /> F z,;[ REMIT <br /> BASE EXPLANATION BILLINGREMITTANCE $ AMOUNT DUE CHECKED <br /> DATE. DATE ,,,fiEMITTED AMOUNT <br /> FEE f CC <br /> "!r <br /> LESS 4 3 I <br /> PRORATION '^•}�; � - T <br /> PLUS l ;t AI <br /> PENALTY s - <br /> � J <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I suan b Date Mailed Delivered <br /> APPLICANT— ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 952€11 <br /> -- <br />