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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> APPLICATION <br /> (For Non-Transferable, 116vocable, and Suspendable) SEPTAGE -� <br /> -r - ILA ENVIRONMENTAL HEALTH PERMIT <br /> Yet 0 LIQUID WASTE f <br /> Appliction is hereby made t car mess in the jurisdictional area of t an J a uin Local altl�D'strict <br /> rn Business Name (DBA) L IAddress <br /> C Address u <br /> a Owner <br /> j Firm Partners, Addresses a I hone NuIT <br /> ers <br /> IL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> InQr <br /> L Applicants Name (Print) ,. TitleOttate <br /> Please check Applicable Category (1-7) and Fill in the Required 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. r" 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. ❑ 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. ❑ SANITATION PERI I <br /> Job Addre O ntinn C ( . <br /> Owner 1 r Addres <br /> SEPTIC TANK 1:1CESSPOOL ACHING FIELD SEEPAGE PIT 1 ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY EW i� REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19}� <br /> Type Construction Disposal_Site- <br /> No. of Units Equipment Storage/CleanzUnits <br /> s) <br /> I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 i <br /> t <br /> Operator Name - Where Certified j <br /> Plant Location <br /> Plant Capacity rved) +: <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More ThaL1,000 Sq Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home ovvneror0censedagent's sInnaturern.tiftest°ethrti,ltheperfofm nce of the work for which thispermit iiissutd;I stiall not.emploY any person <br /> in such manner as to become subject to <br /> Contractors hiring or sub-conlractina s:u.a-._a •; '`;s s' o.t�m'�x�- !.ce'li4Y that in the performance of uze work for which this pet mit is issued,I shill <br /> employ persons subject to workloads compensation ljj>,vs of C-Mciraia. r i <br /> 7 11 <br /> hereby certhaeme prepared th' appIll cation an t at the work will be`done in accordance with San Joaquin County <br /> (ordinances;state laws, ul s an re ul til f t e S Joaquin Lo al ealth\District. <br /> APPLICANT'S SIGNATUR <br /> FOR DEPARTMENT USE ONLY ` <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By,January 31 ❑ July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE REMIT <br /> ANCE $ $AMOUNT DUE CHECKED <br /> i _DATE_ x pATFREMITTED\ AMOUNT <br /> f <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />