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Applications Will Be Processed When Submitted Properly Gompleteu- oeouic -da •• —r.V• .. <br /> APPLICATION <br /> it (For Non-Transferable,Revocable,and Suspendable) SEPTAGF <br /> " ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in1be jurisdictional area of the ano�uin Local He th Distri <br /> aBusiness Name (DBA) ddress— <br /> z Owner Address <br /> a <br /> u Firm Partners, Addresses a Telephone Num ers <br /> aEmergency Telephone No. <br /> IL Business Telephone No. <br /> Contractor Licence No,. <br /> L Applicarits Name (Print) Title 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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> + <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 PERIT r _ <br /> Job Address/Location S' <br /> Oner � � Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD J9 SEEPAGE PIT 11PACKAGE PLANT x" <br /> (] PERMANENT ❑ TEMPORARY �)4EW ❑ 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) _ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where;Certified <br /> Operator Name <br /> 4 <br /> Plant Location <br /> Plant Capacity No. Units Served t' <br /> 7. ❑ LAUNDRY For July 1, -June 30,.19- <br /> SIZE: ❑ Less Than 1,OOD Sq, Ft., ❑ More Than,1,000 Sq. Ft. t <br /> ❑ DRY CLEANING, Chemicals..Used/Amount/Mo. ` <br /> r Ishall not employ any person <br /> #sornemvrerorpcen9edagent sceiUrea'vrteFathe fc,lmune: the work for ihcbthi5 permit isi5sue , <br /> in such manner as to become subiect 101, fkm3'i'S c;.rPea3ati0n t rwS ity i <br /> Contractor's biting or sub-eontrooting signatwee,cyrti eR,,.the_to"Diwins- i Ceitity t11S1 the partofmanoe of the work for wflich this permit is issued,I shalt <br /> employ persons subject to workman's compensation laws of California' <br /> i <br /> I hereby cert ha_t I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state 1a9v -and rules and ftulatipns of a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATU <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 45 <br /> FEE ( & r <br /> LESS f—G�T+OvZ �i eZ I•N[f p�T ,j IT <br /> PRORATIONPLUS <br /> ) // <br /> PENALTY (Jry G!? {jG/PiFJCsI rl1Nr i.dS�aG�✓ �f �fc _�_%i?S� <br /> OTHER <br /> OTHER <br /> m � �� <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 />