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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> APPLICATION ` ` <br /> (For Non-Transferable, Revocable,and Suspendable) y`SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMITS ,. <br /> LIQUI©WASTE "tik • `- � ' `+ ° 4 <br /> Appl icati n is hereb made to carry on busin ss in the ielssdictional area of the an Joaquin Local Health D'strict <br /> En Business Name (DBA) � .�/_ 1� �.�,• "LfC/_�_pAddress` -1 <br /> z Owner - Address <br /> - <br /> U Firm Partners, Addresses and Telephone Numbers <br /> FE Business Telephone No. ���—g��' Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) - S Title Date 144 <br /> Please check Applicable Category (1-7)and Fill in the Required In <br /> 1. 1:1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No y 'CAL. License Renewal3 No. <br /> Capacity Gal.,Weights & Measures No. <br />- EquipmentParking Address - -• <br /> 2. 1:1PUIIJPER YARD f � <br /> y > r <br /> For July 1", June 30, 19 + <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored tr <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Te cation Test Date/Timer ~`' -A <br /> 4. SANITATION PERMIT <br /> Job Add res /Location Z f tJ�/s s?7 XX t <br /> Owner A* <br /> —w L,� Address 'f <br /> ❑ SEPTIC TANK ❑ CESSPOOL CHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> W,P-ERMANENT ❑ TEMPORARY ❑ NEW EPAIR{ ❑ OTHER <br /> .5. ❑ CHEMICAL.TOILETS For July 1, -June 30, 19 <br /> Type Constructii♦o'n .6 Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator..N.ame y - _ - Where Certified. <br /> Plant Location <br /> Plant Capacity f t No. Units Served r <br /> 7. .❑ LAUNDRY For July,1, -Ju.6e 30,.19 <br /> SIZE: ❑ Less Than 1,000 Sq. FL,= ❑ More-Than,j1,000•Sq.1.Ft,, ` <br /> ❑ DRY CLEANING, Chemicals Used/1Arf ount/Mo. * r w"" <br /> DomeownerorNeensedagenPs signatuiatertifiesthAfollowing:"I certify that in the performance of the work forwhick this permit is issued,I shall not emptoy any person <br /> in such mannE,as to becorne subject to tvorkmao's coropen:atiorl laws of CaTifornia." _ <br /> Contractor's hi!ing or sub-contractingsignature n6rtifi8s the foltotruitlg: "1 Ct rtify that in to .per ormani e; .[tle_w.vrk.lor�llickth s permit Ivssued, <br /> employ persons subject to vaorkmaa's compensation laws of CaMorria." �- <br /> (# I hereby-certify that l fiat/ r repared this application and th t the work ill be done in accordance with San Joaquin County <br /> ordinances, state laws, J u and re ul ns of the Joaquin al Heal h District. ' <br /> j <br /> APPLICANT'S,SIGNATURE X <br /> r .,,... <br /> FOR DEPARTMENT USE ONLY - <br /> 1 <br /> 3✓Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ,. -❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> ti ti - - f REMIT <br /> BILLING ,REMITT N E __ $_._ <br /> BASE - EXPLANATI'ON - - AMOUNT DUE CHECKED <br /> ~'1 DATE rD E ".;� SREMITTED AMOUNT <br /> FEE ! f� ri-...-«"°-�•,�.M -r, .may'..,\.... Q— <br /> t <br /> LESS J <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> + ! <br /> OTHER <br /> ,.. OTHER <br /> -a- <br /> Received by by •. Date Receipt No. Permit No. - Is uance Date ailed delivered <br /> APPLICANT-RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HAIELTON AV .Box 20(19 STOCKTON,CA 95201 - p <br /> 1 <br />