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..�,...__.._.._ ..... ... . ,.,_....�,. ....�,, wuuuuea rrupeuy c.uatpreteu. nae aure 1 o wiln I ne Application. <br /> APPLICATION <br /> W "Ilyor Non-Transferable,Revocable, and Suspendabas/ <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatii is hereby made o car on Duel ess in e'uris 'ctional area of the S a ui ocal IV <br /> Ith Distric�j �, <br /> �usines ame (DBA Address d'yC �% /ted.' <br /> e Owner IAddress Se� <br /> =irm Partners, Addresses and TTe_le hone N bers <br /> Business Telephone No. �. �/O S Emergency Telephone No. x <br /> Contractor Licence No. <br /> Applicants Name (Print) T'NR U_ PP Data (I <br /> 1 <br /> _please check Applicable Ca ory (1-7) and Fill In equired Information �1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> cor July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> wterial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> quipment 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 /> Pes,t�L,�oc ion Test Date/Time <br /> —4. lar SANITATION PERMIT <br /> Job Add re /Locatio <br /> Owner �'� Address <br /> ..i7 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD E SEEPAGE PIT PACKAGE PLANT <br /> IB'GERMANENT ❑ TEMPORARY ❑ NEW [&-REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Od <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 /> Dperator Name Where Certified <br /> —Plant Location <br /> Plant Capacity No. Units Served <br /> /. ❑ LAUNDRY For July 1,-June 30, 19 <br /> 3IZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Homaownererlicensed agent's signature certifies the following:"I certify that in the performance of Me workfor which this permitis issued,l shall net empleyany person <br /> in such manner as to become subject to workman's compensation laws of California.' <br /> Contractor's liking or sub-contracting signature eerbffes tha folbvring: "I certify that in the performance of the work for which this permit is issued,I shag <br /> employ persons subject to workmai s compensation laws of California" <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, d rules a nn/QQ/���e..g/y��ations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �`"" � �— <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE $BREMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT -p. <br /> Q¢ \ <br /> FEE <br /> LESS <br /> v. PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _ <br /> r Received by Date Receipt No Permit No, Islivance Data Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1e01 E.HAZELTON AVE.,P.O.hoe 200 STOCKTON.CA 95201 <br />