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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE - <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District cam, <br /> y Business Name (DBA) X0 YAddress ��k IW�d .1�L`��znl <br /> ? Owner Address <br /> a _ <br /> J Firm Partners, Addresses andTelephoneNumbers ; <br /> aBusiness Telephone No. Emergency Telephone No. - <br /> a Contractor Licence No. <br /> L Applicants Name (Print) - , Title MAN A4E—Z; 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, 191 DiSposaI Sites = <br /> Description(Make/Yr., Color) — <br /> Serial No. w c 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 r <br /> No. of Vehicles Stored <br /> Na" of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> r , <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L cation Test Date/Time <br /> 4. MUNITATION PERMIT <br /> Job Address/Location 2 ■ <br /> O er '��SCC �_b 1SRS Address , z -A&.4 Y <br /> SEPTIC TANK ❑ CESSPOOL .❑ LEACHING FIELD; ❑ SEEPAGE PIT El PACKAGE PLANT <br /> PERMANENT [] .-TEMPORARY_ �0`;NEW .REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS A For July 1, -June 30, 19 p <br /> Type Construction { Disposal Site �J <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6 © PACKAGE TREATMENT PLANT For July 1, -June 30, 19 V <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 /> .-Homeowner or licensed agent's signatlrreaertif osthe following:'t certifv tbM in theperftwm ante of the work for which this permit is isgued,f shall nat em <br /> ploy <br /> in such manner as to fiecnme subject to workman's campensafinn lavas of Cafiturlr3 <br /> Contractor's hiring or sub-contracting signature terrifies the,foNowving. '1 certify that in the PerfOrmance of the work for which this permit is issemploy pet'sons subject to workman's compensation laws of Californias," <br /> I hereby certifythat I have repared this application an at the work will be done in accordance with San Joaquin Count <br /> ordinances, state laws, ulqp and reguvrRns of theJoaquin ai alth District. <br /> APPLICANT'S SIGNATURE X <br /> r FOR DEPARTMENT USE ONLY _ <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE S C a <br /> LESS <br /> PRORATION, <br /> PLUS <br /> .PENALTY <br /> OTHER Q e <br /> OTHER <br /> Received by Date Receipt No. Permit No. - I uanc Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Buri 2009 STOCKTON,CA 95201 - <br />