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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) i <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is reby made to car on busi ess in tile jurisd' tional area of the San Joaquin Local Health District >> i <br /> yBusiness Name DBA) - Address <br /> z Owner i Address <br /> a � <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> 4pplicantNam ,(Print)-- _ Title Date <br /> PleaAse check ApplicableYCat'egory(1-7)and f ill in the Required Information <br /> 1� ❑'iPUMPER VEHICLE.PERMIT REGISTRATION (FOR EACH VEHICLE) I" F <br /> For July,1, June:30, 19 Disposal Sites <br /> 4 Description.(Make/ :V;,. -olo"r)"R" <br /> _ CAL. License No. CAL, License Renewal No. <br /> Serial Noy <br /> Capacity Gal., Weights &Measures No. t <br /> equipment Parking Address <br /> 23.V❑ 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 /> V1bR.S. or R.C.E. No. <br /> R.S. or R.C.E. Named <br /> Testi dtion v Test Date/Time <br /> 4. u SANITATION PE�_i_MIT <br /> Job Addre Location. c <br /> Owner' ��'``� "� Address <br /> SEPT C TAN4 <br /> lbxGESSPO- 'El-LEACHING FIELD S�•EPAGE PIT ❑ PACKAGE PLANT --w <br /> ❑ PE AIVENTt�TO <br /> TEMPORARY ❑ NEW REPAIR OTHER <br /> 5. ❑ CHEMICAILETS For July 1 -June 30, 19 <br /> Type Constructio1t Disposal Site W <br /> No. of Units # Equipment Storage/Cleaning Location(s) <br /> 0 ! IF <br /> } <br /> 6. 11PACKAGE',TREATMENT PLANTIAF6r,July 1, -June 30, 19 <br /> OperatoriName _ Where Certified <br /> Plant Location �a <br /> Plant Capacity No. Units Served <br /> 7. ❑ LA,UNDRY� For!-Jul yYi;June-�30, 19 <br /> SIZ�- Less7Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ D.RY GLEANING,Chemicals Used/Amount/Mo. ' <br /> +Kr. Aapewit'segiratrp�e.slillrs�Mte�s..4�:'Ytert_ lflatintheperfonnaltcoeNtft��rlttpf tiftperfllltisIssued,IShall"Memployanyperson n <br /> k[:such manner zs to become subject to workman's=c0iopetiiW`ri laws of fornia.' ['-"' <br /> Coriteiaotct's hidnq or a dl-eai __ skmum 0erti%s the �- �'1 certify that fn the performance of the work far which this permit is Issued,I shall <br /> employ persons subject'to7vorkman's=t:ampensatioll iaws of California" —fl <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 pples and regulat' ns f the San Joaquin Local Health District. _ <br /> APPLICANT'S SIGNATURE X <br /> FORENUSE ONLY { <br /> Fee Is Due: ❑ ANNUALLY _ ❑_ PER UN1IT ❑ PER SITE 1:1 EACH ElJ�nuary 1 &R$ceived 8y Janu_ ry 31 El Jul.1 &Received'8y July 31 <br /> REMIT <br /> BASE EXPLANATION y BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUN ' <br /> FEE— <br /> LESS EE+ <br /> PRORATION <br /> PLUS 1 <br /> PENALTY [[[t <br /> OTHER <br /> OTHER. <br /> Received6y., Date -� Receipt No- Permit No. I s a�rcdSDate Mailed Delivered f <br /> APPLICANT—RETURN ALL COPIES TO:^ ENVIRONMENTAL HEALTH PERMIT/SERVICES —x,._.7665 E.HA2ELTON AVE.,PA.Bob 2a D4 STOCKTON,CA 95201 <br /> _�., lid pi`1 <br />