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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> f (For Non-Transierable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LlQilia WASTE f <br /> Applicatio hereby'mad to carry on business in the juri ictional area of the San Paquin Local Health District <br /> y Business Na a (DBA) Address j`� <br /> z Owner Address <br /> a i, <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No..—3/6A 5z 6 9 Emergency Telephone No. <br /> Contractor Licence No. Z t <br /> Applicants Name (Print) a 1I' Title Date Ss �� <br /> Please check Applicable Category (1-7)and-Fill in the Required Information (f� <br /> 1. 1:1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June-30, 19 — Disposal Sites <br /> Description(Make/Yr., Color) • d <br /> Serial No. <br /> " CAL._,4icense No.. CAL. License Renewal No. ' <br /> i <br /> Capacity `,-Gal:T•Weights & McAsures'No. <br /> Equipment Parking Address a ) <br /> ^2. ❑ PUMPER Y4RDi4_" t' I <br /> "For July 1, June 30, 19 lop, a t <br /> e, if <br /> #No:'of Vehicles:Stored <br /> r <br /> No. of Chemical Toilets Stored <br /> 3. C) PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test ol tion Test Date/Time ' <br /> 4. SANITATION PERMIT > I. <br /> Job Address/Loc ti n Z' <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD (PAGE PIT El PACKAGE PLANT 1 � <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER //b <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 ? ` <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cl'eaning L"ocation(s)""'"""". U <br /> r 1 <br /> 6. 13 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> Operator Name Where Certified <br /> Plant Location t <br /> Plant Capacity No. Units Served <br /> June <br /> � f <br /> .7. -❑ LAUNDRY> For July 1, -June 30,.19 r k <br /> SIZE: ❑ Less Than 1,000 Sq. Ft. �Cl"Mc re-Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> s l 3 i <br /> Home owner or ltcersaed agent's signature Certifies "f Certify that In the perfosmaRceof the work farwhii h this permit is issued,i shall trot empl oy any persors <br /> in such manner as io become subject to v/arkfna!f's c�mt le7saticrt tars c;"a ifotnia"• t J f � <br /> Contractors hilrin4, or sub-Contra' gnn:urF.:,ar:ifie; the following. "1 certi,;,Mut IR the perfoi:nance of'tie work for wbich this permit is issued,"!shall' y/► <br /> employ�ersoris�suti);;ct to tvarkman's col>tip�sa`li3n iuvry of Caiia:aia.'" i f ` <br /> I"-; reby certlty"thYat`i'havegprepared this application and that the work will-be done in accordance with San Joaquin;County <br /> ordinances, state laws, and rules aVretions of the San Joa in Local `ealth District_ <br /> APPLICANTS,SIIGNATTURE X r_ I 5 <br /> :. •, <br /> FOR DEPARTMENT USE ONLY. <br /> Fee Is Due: ❑ ANNUALLY i ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 _ ❑ July 1 &Received By July 31 <br /> REMIT t <br />- BASE EXPLANATION BILLING REMITTANCE $ CHECKEDi' <br /> AMOUNT DUE <br /> DATE DATE REMITTED f'AMOUNT <br /> ° <br /> FEE <br /> LESS I' <br /> PRORATION <br /> PLUS l <br /> PENALTY `• - - - i <br /> OTHER . <br /> OTHER q <br /> `Received by Date - Receipt No. Permit No IPuante Date Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20009�OC KTON,A 95201 <br />