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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The App <br /> lication. v <br /> APPLICATION <br /> (For Non-Translerable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> VIP LIQUID WASTE <br /> Applicat' is hereby ma e to carry on busines i he j risdictional area of the 5qE1JoaquW Local Health District <br /> F Business me (DBA) Address <br /> ! C Owner Address <br /> Firm Partners, Addresses and Telephone umbers <br /> CL Business Telephone No. <br /> a Emergency Telephone No. <br /> Contractor Licence No. Z <br /> a Applicants Name. Print Date <br /> L (Print)} Title a <br /> Please check Applicatile'G gory(1-7) and Fill in th 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. Liccase Renewal No. <br /> Capacity "' .: Gal., Weights &Measures No. }` <br /> F .Equipment P4rking,Address.- <br /> 2. ❑ PUMPER YARD x' t <br /> i For July 1, June 30, 19 f <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> t <br /> . 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Loi tion ` Test Date/Time i <br /> i 4. SANITATION PERMIT ` <br /> Job Addr ss/Location <br /> i ,O�wn�er Address ' ' �•t.� _ d 1 <br /> L�'O�'S�E IC TAN CES OOL"' 5P�ACHING FIELD ❑ SEEPAGE PIT El PACKAGE PLANT <br /> F'tRMANENT ❑ TEMPORARY— ' Cs}�W ❑ REPAIR Pgfllem- � <br /> i' 5. ❑ CHEMICAL TOILETS Foy July 1, -June 30, 19 <br /> -"^ <br /> Type Construction Disposal Site--�-�--- <br /> +No. of Units ` Equipment Storage/Cleaning Location(S) <br /> I 6. ❑ PACKAGE TREATMENT PLANT T For July 1, -June 30, 19 <br /> +Operator Name =+ <br /> t Where Certified --- I <br /> i <br /> Plant Location "t <br /> Plant Capacity No. Units Served <br /> I 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> ' r f <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> `❑ DRY CLEANING, Chemicals Used/Amount/Mo.- fir; f <br /> i Ilfomeownerarlicanaedagent•ssignahrrecartifieatha ftterti thatIntheperformanceoftheworkforwtticlltitisp`ermit'isfssued,lshallnatemployanyperson <br /> in such manner as to become subject to workman's compensate{a vs of California." <br /> COntil'bM's hiring or syb-cantiacting signature Certifies the <br /> employ persons subject to workman's compensation laws of Calitornia.- f certify that in lhe,performalice of the work for which this permit is issued,I shall <br /> I hereby C4r6ify fhat'l haveprepared[his application and that the work will be done,in accordance with San Joaquin County <br /> ordinances, state laws, d rules an gu tions 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 &Received By January 3S ❑ July 1 &Received By July 31 <br /> u g BASE �EXPLANATION BILLING{ - REMITTANCE - R IT/////1M/����//1�� <br /> y DATE DATE I,x REM TTED _AMOUNT CH K� <br /> FEE �. � UN fi A. <br /> LESS - <br /> +J``PRORATION .' v ,�- w ., ...•L� G� ryj <br /> PLUS ` —1 <br /> PENALTY <br /> f <br /> OTHER' <br /> OTHER00 <br /> ' <br /> 55 ! r <br /> Received ve—by Date - Receipt No. ermit No. - issliancei Date Mailed Delivered <br /> .APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2049 STOCKTON,CA 95241 - <br /> i <br />