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Appucaions win as rrocesseu Innen auommeo rropeny r ompteteu. oe oure I u argn i Re npptmauu... <br /> APPLICATION <br /> hrl'Non-Transferable,Revocable,and Suspendabl4y,,,1 SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio is arab! ad to car u s in the jurisdictional area of the San JOB LoecgI Health Dg Inct <br /> Business a (WA) � �b I LAddress le ��C ��! <br /> i Owner Address ��i r r t <br /> s <br /> Firm Partners, Addresses and Telephone Numbers <br /> 'la Business Telephone No. erg 3 r7 Emergency Telephone No. sem`— <br /> ..7. <br /> Contractor Licence No. a �•- "� <br /> L Applicants Name (Print) Title mLd�� Date3i <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ElPUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Ui <br /> For July 1, June 30, 19 Disposal Sites 'T2 <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 Location Test Date me <br /> 4. ❑SANITATION PER IT <br /> Job Address/ ation .� Q etti <br /> Owner /i &.,ew Address t' <br /> GL'StPTIC TANK ❑ CESSPOOL W<EACHING FIELIGE PIT ❑ PACKAGE PLANT <br /> Lr PERMANENT ❑ TEMPORARY ILL44EW ❑ REPAIR ❑ OTHER S <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 N <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 /> Operator Name Where Certified <br /> Plant Location - - - - --- <br /> Plant Capacity No. Units Served - <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 CLEANING,Chemicals Used/Amount/Mo. <br /> Home ownerorgeelwd agent's signaturecer"est!tefnnowirtw"I card},"hat inthe psrfofmancsof 6lework forwhioh this permit is Issued,I&hall not emploY Any pfffsoe <br /> in such manner as to become subject to workman's compensation!aws of C�Yarllia." <br /> Contractor's Mrinq or sus-contrecrinp cit;•- n-• ceta9 c .`:Itow Ant, "i lte ll(y that In the performance of the work for~this permit is issued,I&hall <br /> employ persons subject irws a uLunu;i eJ ' <br /> I hereby certify that 1 have prepared this application d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an nd re ations of t J uin Local Health District. <br /> APPLICANT'S SIGNATURE X y--Fly <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 /> BILLING REMITTANCE E REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE dr .\.n'`,♦�'' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -y <br /> Received by Date Receipt No. Permit No. I suanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 200 ST C"ON,CA N 1_' <br /> ' reA� <br />