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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 her by made to caVy on business in the jurisdictional area of the San Joaquin Local Health trict. <br /> F Business Name (DBA Address ; <br /> z Owner _ Address <br /> a <br /> Firm Partners, Addresses and Telephone Num e�, <br /> aBusiness Telephone No. _ E,0G Q,4 Emergency Telephone No. <br /> Contractor Licence No, <br /> �:dK <br /> Applicants Name (Print) 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(MakeNr., Color) <br /> ,T e <br /> Y' 4 CAL. License No. R x CAL. License Renewal IVo <br /> Serial No. - <br /> Capacity Gal.,Weights & Measures No. ��' _x. ' <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD aF <br /> ' r ♦W <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored t„ , <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name .`! ' R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT �A �] <br /> Job'Address/Location , <br /> Owner ress.� <br /> ❑ SEPTIC TANK CESS OOL ACHING FIELD ❑ GE PIT PACKAGE PLANTfr) j� <br /> ❑ PERMANENT ❑ TEMPORARY NEW REPAI ❑ THE <br /> t� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ` � f <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 /> .. <br /> Plant Location r.r} <br /> Plant Capacity No. Units Served �! <br /> i� 7. ❑ LAUNDRY For July 1, -_June 30,19 <br /> f SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 4 <br /> t <br /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I Harnuaw"rat9consedagent1nsturecertefieathsfotlowing."Icertify that in the perfor anceofthe work for which fhispermit isissuKIshall not employ any person <br /> insuCh nlsmtar astobhcoMesubta Ilt+erlcmatt's torrlpieltsatien IawS Of�iefiiGrrl:..•' <br /> yrs hltirly or sigrwww ceAMos the tAtt�+xir+g: "I certify that i. the pertormanee 0 the Wor#r for WDICh fhfs permit is issued,!shall <br /> employ persmrs siiW to warms s comperisatien lams at calitrltrl}'. <br /> i <br /> I hereby certify that I have prepared this application d that the work will be done in accordance with San Joaquin County ` <br /> ordinances, state laws, and rule and regul ti ns of 'e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ` <br /> FOR DEPARTMENT USE-ONLY <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> t BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> E BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS "l <br /> PRORATION <br /> f PLUS F <br /> PENALTY <br /> OTHER <br /> OTHERo j�- '"� <br /> . i <br /> E_ <br /> Received by Dat # Receipt No. ermit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES "1601 E.NAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />