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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. E <br /> APPLICATION <br /> f`---^— (For Non-Transferable, Revocable,and Suspendable) 9 <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBAj' Address <br /> aOwner ), J1,> �{� .�� Address <br /> L) Firm Partners, Addresses and Telephone Numbers 1235 r <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. o� v <br /> Applicants Name (Print) Titlen41L Date <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 4 <br /> Description(Make/Yr., Color) ^� <br /> Serial No. CAL. License No. CAL. License Renewal No. -� <br /> Capacity Gal., Weights & Measures No. r <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 PERMIT <br /> Job Address/Location 3� j <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR _ ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) J <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location a '� <br /> ..i <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 Y <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. I <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Hama ownerarlicensed agent's sigrsat <br /> -ire cortifleathefottowing:"I certify that in the performance oftheworkfor which this per;ri1Wt1tp <br /> mp akfyperson <br /> in such manner as to bac,me subject to wrork7la s carrpensation laves of Cal4ofaiz, <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work is t i&ed,I shall <br /> employ persons subject to workman's cotrpensa:ian is f s o3 Califorria." <br /> hereby certify that I have prepared this application and that the work will be done in accordance with S Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 3 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ - .i <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORAT$ON <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> L>6014ed by Date Rec ip o- 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 />