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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ` <br /> r APPLICATION <br /> I (For Non-Transferrable; Revocable;and Suspendable) SEPTAGF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE' <br /> Appl ication�ereb made t rry on us ss in the jurisdictional area of the San Joaquin Local Health District <br /> ` rBusiness Name (DBA) Address <br /> a Owner— 14;ola &Jicz 4rAnd :Address <br /> „ .,...T <br /> . 2 Firm Partners, Addresses and Telephone Numbs <br /> CL Business Telephone No. 1 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print): ` Title Date �O } <br /> Please check Applicable Category (14)and Fill`in the Required.lnformaHon <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, .June'30, 19. �y _�-;� =;--:.,Disposal Sites -- <br /> v <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. - "`~ CAL. License Renewal No.' <br /> Capacity Gal., Weights &Measures No's <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD S <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name x R.S_or_R.C.E. No.~ i <br /> Test Location Test Date/Time <br /> 4, SANITATION PERMIT 1 <br /> Job Address/Location '-/5— dD t a!' Aoj <br /> Owner Address <br /> ❑ SEPTIC TANK- ❑ CESSPOOL 1 . ❑ LEACHING FIELD . SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY r ❑ NEW ARLIREPAIR ❑ OTHER t <br /> i 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 , - � <br /> l Type Construction ,, t Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <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. # f € <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. t <br /> Home ownor orlicansad agent's signature certifies the faHaiving:N CBt'ti7 thavn theperformanu of thework forwhiOthis permit is issued,l shall not employ any person <br /> t in such manner 9s to become.subje to workman S,'r3Ti,^.�I1�'1i13R 13Y;5''_ {�S�itvq'frl aF <br /> Contractor's liking or ,u!)-contracting cartifie- -he tz'Alo virrg: "i certify th2t1 to the performance pt thewl)rk for which this pertnit is issued,I stiall <br /> employ persons subji cl to workman's colnpcnsation laws of Calfiornia.` } <br /> f <br /> I hereby certify that 1-have prepared this application and that the work will be done in accordance with San Joaquin County _ <br /> ordinances, state laws, and s and reg ations the San Joaquin Local Health District. <br /> ! APPLICANT'S SIGNATURE X y � <br /> ., <br /> r FOR.DEPARTMENT USE ONLYI .- <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 /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE <br /> CHECKED <br /> kk. DATE—} r IRATE _ - REMITTED AMOUNT <br /> FEE : lS <br /> LESS. . <br /> PRORATION..' - U Z <br /> Ptus <br /> PENALTY <br /> .. OTHER <br /> - <br /> OTHER <br /> A. <br /> _F, t <br /> Received by , 'Date -Receipt No:. Permit No.-4 . Issua ce Date -Mailed elivered <br /> APPLICANT''RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HA2ELTON AVE.,P.O.Box 2009 5TOCKT N,CA 95 1 - <br />