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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 Q� <br /> LIQUID WASTE S l O p <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,,Business Name (DBA) Address <br /> � <br /> Address ?7• �U L wipr-N f 414 01523( <br /> Firm Partners, Addresses and Telephone Numbers Zf32s F Al L19-T4— <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) � a� f' Title 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, 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 ghemical Toilets Stored <br /> 3. 931PERCOLATION TE f <br /> R.S. or R.C.E. Nam�etr �t _ R.S/or�C.E. NO. <br /> Test Location d �� i-- '�` T st Date Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER # 4 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 J <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 "J <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 owneror licensed agent's signature certifies thefollorlring:"I certify that intheperformanceof the work for which this permit is issued,I shall not employ any person <br /> In such manner as to become subject to workman's campansation laws of Calitornla, <br /> Contractor's hiring or sub-contracting signature certifies *a folkwitingz A certify that in the performance of the work for which this.permit is issued,I shall <br /> employ persons subject to workman's compensation laws of Catifotrda.'• <br /> I hereby certify that I have prepared this applicat.on and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws d s an4 regu ons of SanJoaquin 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 &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 AMOUNT <br /> FEE pp C)O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> o <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />