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P4N Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> t APPLICATION <br /> (For Non-Translerable, Revocable,rand 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 r <br /> Ur Business Name (DBA) - Address <br /> aOwner Address li` lip X., <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> .J Contractor Licence No. - <br /> Applicants Name (Print) O Title —. Date g'Z3 Y <br /> Please check Applicable Category.(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) N <br /> For.July`1,4 June 30, 19 Disposal Sites - - <br /> Description(Make/Yr., Color) I <br /> Serial;NoN CAL, License No. CAL. License Renewal No. v <br /> Capacity "' Gal.';Weights & Measures No. <br /> Equipment Parking Address l <br /> 2. ❑ PUMPER-YARD i • <br /> For July 1, ' k-.June 30, 19} <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 t;f-,_ R.S.or R.C.E. No. <br /> Test Location ! "' ( Test Date/Time <br /> 4. 11SANITATION PERMIT V \ � 9 Z <br /> Job Address/Location r- 5� y��'" N, 0 k <br /> Owner i T4�- �j" (7 r - --Add ress <br /> ❑ SEPTIC TANK 0 CESSPOOL ' LE'ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑`TEMPORARY El NEW' REPAIR OTHER �(�j.�`(}Y, 7'ajti-71Gy�� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 i �1 <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 <br /> Where Certified <br /> Plant Location - v <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. V <br /> Home owncnorlicensed agent's signature certifies the follorring:"I certify that it the pertnrmance.ofthe wark for which this permit isissued.!shat!not employ any persory <br /> in rh manner as to 6eceme stshlect to vrorkmat s cnl�Ipens3tial laws of Cati€omia" h <br /> Contrector'S hiring ct sup-eortrac:cl sib atzer•i{ins the following 1 ce if fl <br /> le p r e tt'y that G! 1 perforrran�e of til^wcl k tor:vhicll t?<s errlif ;shall <br /> e sans suL; ct to tivorkmae's ccrlfl;.^ ioe,ial,.�s of Caii€orrl�.. :� :s i.�-: - <br /> � I hereby certify that I have prepared this application and that the work will be dobe in accordance with San Joaquin County <br /> ordinances, state laws, and rules and redulations of the San Joaquin Local Health District. <br /> APPLIGANT'S SIGNATURE X <br /> r � i <br /> Z <br /> FOR DEPARTMENT USE ONLY <br /> i <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 /> r � BASE EXPLANATION ,BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i DATE DATE REMITTED AMOUNT <br /> I FEE <br /> LESS i <br /> PRORATION <br /> PLUS <br /> -PENALTY <br /> r <br /> OTHER <br /> OTHER �- <br /> r <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009' STOCKTON,CA 95201 - <br />