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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 /> Applicat' is hereby mad to car o b sines i.1the j risdictional area of the S oaqul ocal Health Distr'tc ' <br /> FBusines ame {DBA) Address— �•___ /f' <br /> C Owner Address <br /> 1 Firm Partners, Addresses andelep one Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 2 Z Z <br /> L Applicants Name (Print) Title Date 7 - <br /> Please check Applicable Cat ry (1-7)and Fill in tOgRequired 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 d f <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST r <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 3 <br /> OweSAddress • 1 9 <br /> l EPTIC TANK ❑ CESSPOOL 21LEACHING FIELD 21SEEPAGE PIT 13PACKAGE PLANT F <br /> G!r'PERMANENT ❑ TEMPORARY 1:1NEW U REPAIR ❑ OTHER ._. <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �C/,J <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> f <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 /> Homeownerorlicensedagent'ssignaturecertifiesthefollowing:'lcertify Rip!? nihepnrformanceefthe'workforwhichthispermitisissued.Ishallnotemployanyperson �✓ <br /> in such manner as 10 becorne subjecm'N(ilI mrw'S compensation IRws of Califomma.' <br /> Contractor's hiring or sarr•r:a tract'snq sit <br /> nature terrifies the following: -1 certify that in the performance of the work for which this permit is issued,I shall F <br /> employ persons subject to ararkman's Compensation laws of California.' t <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, an rules and r ulatt ns of the San Joaquin Local Health District. _ s <br /> APPLICANT'S SIGNATURE.. } <br /> FOR DEPARTMENT USE ONLY E <br /> 3 <br /> Fee Is Due: ❑ ANNUALLY ❑'PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1'&Received By July 31 <br /> { BILLING.- REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION DATE - „DATE RE=MITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ti <br /> PENALTY <br /> OTHER <br /> a <br /> OTHER <br /> Received by Date Receipt No. Permit No. 1p&uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bow 2009 STOCKTON,CA 95201 <br /> �� 4� -P4 �/--h{pL <br />