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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION s <br /> (For Non-Transferable,'Revocable,'and SuspeYldable) SEPTAGE j <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> Applicatio Is hereby made to carry on bu iness in the jurisdictional area of the�an Joaquin Local Health District <br /> y Business Name (DBA) �• I,Si c?oe _ _Address ' '�• cS"f�'�«+/ 929 <br /> i Owner Address <br /> U Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) _` Title Date <br /> Please check Applicable Category(1-7)and Fill in the Req uir d Information I T <br /> ,1. =❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) y <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 <br /> No, of Chemical Toilets Stored '- <br /> 3. ❑ PERCOLATION TEST i <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 P <br /> I <br /> Owner- Address <br /> �:'SiPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 0 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 , r <br /> Type Construction Disposal Site <br /> No. of Units - Equipment Storage/Cleaning LocatioIn(s), <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, --Su a 30, 19 .r3" <br /> Operator Name rr Where Certified.' f - <br /> Plant Location - f <br /> - _� - '.. - No. its Served ` <br /> Plant Capacity —`•'� ` '- � �" _ — , <br /> 7. .❑ LAUNDRYg For,July 1,-June 30,19 <br /> SIZE: <br /> El Less Than 1,000 Sq! Ft., ❑ More Than 1,000 S. ' ti+"A '" . <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home Owner or licensed agent's signature certifies the following:Ill certify ttsal(in tht perf&inance of thework for vrltich this permit is issued,l shall not employ any persotr <br /> in such manner as to become sgnject to worl.malfs cmnperlsatiur<la4:f5 of Califur'nia:­ .t <br /> Contractor's:hiring or.'sob contracting &ignaturo fortifies the followlnpi_A petiity that in the performance of the work for which this pemtit is issued,I Shall <br /> employ persons subject to workman's compensation laws of Califa fila." a <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r s ae lations of n Joaquin Heal <br /> ni rDistrict. <br /> APPLICANT'S SIGNATURE. <br /> -FOR DEPARTMENT USE ONLY W <br /> } <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 $r AMOUNT DUE CHECKED <br /> DATE.,' DATETL i REMITTED AMOUNT <br /> FEE , z r CS - <br /> LESS r € <br /> PRORATION i <br /> PLUS Y 2 <br /> PENALTY <br /> OTHER . <br /> OTHER <br /> l �-5 v 2 vCM <br /> Received by Date Receipt No. Permit No. Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.O:Bqx 2009 STOCKTON,CA95201"' <br />