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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �1 (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application re Wmade t9Jrry on b iness in the jurisdictional area of the San Joaquin Local Health Distri / <br /> H Business Na (DBA) Address, '57: A�S. aiQ� <br /> aOwners Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. If .7z Emergency Telephone No, <br /> 1z C <br /> Contractor Licence No. Of <br /> L Applicants Name (Print) 10 Title 2$ Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information 1 <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. IJ PERCOLATION TEST + <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. RLSANITATION PERMIT <br /> Joh Address/Location <br /> Owner Address dA <br /> ❑ SEPTIC TANK ❑ CESSPOOL P<ZACHING FIELD r,lK� EEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 1:1 TEMPORARY 1:1NEW �FEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site O <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 x <br /> Operator Name _ Where Certified <br /> Plant Location <br /> Plant Capacity r. 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 /> Homeowner orticensed agent's signaturo ce-tif:esthe fuEtowing:"1 comfy that in the oerformance of the work for which this permit is issued,Is hall not em: .Gy l ny <br /> in such manner as to bewMe suiljml t0'rrt rkn a is;0 T pelts&ti0,la z;of CSlif'Sxli ." <br /> Contractor's hiring or Sub-contracting signature cer0fien clic following: "i certify that in the performanca of the work for which this perrnH issr,A. <br /> employ persons subject to workman's compensatioa Paws of California." <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sin Joaquin County <br /> ordinances, state laws, and r s 11 d reg tions;Vhe San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jury 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANAT10y AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �j AMOUNT <br /> FEE Ll <br /> S <br /> LESS <br /> PRORATION <br /> PLUS " <br /> PENALTY1 ! <br /> OTHER <br /> OTHER <br /> 7 L'j? <br /> Received by Date Receipt No Permit No. Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />