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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH.PERMIT ] <br /> LIQUID WASTE r <br /> Application is r y made toonDusi s in th i risdicti nal area of the San Joaquin Local Health District <br /> H Business Na DBA) ` � Address_ 1 00 ' _ Cgf7 <br /> z Owner_. B r ,42,!w <br /> Address .� <br /> -ca_�.r <br /> Firm Partners, Addresses and Telephone Numbers <br /> CLBusiness.Telephone.No.. � S G Emergency Telephone No. Y <br /> Contractor Licence No. <br /> Applicants Name (Print) _ i ,Ti_tle � Date 4 <br /> Please check Applicable Category..(.1-j).And Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; June 30;..1.9 Disposal Sites <br /> r <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test ocation Test Date/Time $ <br /> A. "MSANITATION PERMIT <br /> Job Address/Locat' n <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD .,'SEEPAGE PIT ❑ PACKAGE PLANT <br /> 13 PERMANENT ❑ TEMPORARY ❑ NEW REP-AIR -. ❑ OTHER n x <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ¢ 4- <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 /> ' <br /> ,Operator Namefes,. Where Certified <br /> Plant Location'. ' <br /> Plant Capacity No. Units Served F <br /> 7. ❑ LAUNDRY';For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEAN ING,'Chemicals Used/AmounUMo. <br /> No"ownievorficen"d Mont's sigmtumcardfivalthafaftowilag:1 cerIlly Malin the pWormanwal the work lorwhich this permit issued,I shall not employ any person- ) <br /> in such manner as to become subj4lci to workman's covipensahm laws of catffornti:- " <br /> con.actor's 1*1 Ig or cxED•camracting sgratule C*rwiea Ow labouring: 1 certify that in the peaforMVyce of the work for which this permit is issued,I shall <br /> empio rr persons sutgect to workman's compensatianfaws of California t <br /> I hereby certify that.I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rujIgAand reguI tions'o the San Joaquin Local Health District. } <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY. ., <br /> t Fee Is Due: ❑ ANNUALLY ❑ PER UNIT`S ^-Ej PER SITE - ❑EACH ❑ January 1 &Received By January 31 ❑ July,1 S Received By July 31 3 <br /> REMIT <br /> BILLING REMITTANCE $ 1 <br /> BASE EXPLANATION pgTE DATE REMITTED AMOUNT DUE CHECKED <br /> B AMOUNT <br /> i y <br /> FEE w n — - <br /> LESS <br /> PRORATION E w <br /> PLUS + <br /> i- PENALTY <br /> OTHER '' t c; h4 z <br /> OTHER <br /> Received by Date Receipt No. Permit No _ Issuance Date Mailed Delivered <br /> APPLICANT,-RETURN ALL COPIES'tO:__1 ENVIRONMENTAL HEALTH'PERMITISERVICES 1601 E.-HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 . <br />