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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendabte) SEPTAGE <br /> 05 <br /> i ENVIRONMENTAL HEALTH PERMIT /� 7 <br /> LIQUID WASTE`' <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) Address—,L0i <br /> z Owner. ;e�, 7_. �a G 4C'dZ� Address <br /> a :-, . - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. - _ Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title �/�*✓ ✓ Date ro4,1r'1, <br /> Please check Applicable Category(1-7)and Fill In the Required Information W <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1. June-30,9-9:- Disposal Sites - <br /> Description(Make/Yr., Color) j <br /> ' Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> i Equipment Parking Address E <br /> } 2. ❑ PUMPER YARD N <br /> For July 1, June 30, 19--� <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> -3.. ❑ PERCOLATION TEST ' .s ' <br /> R.S. or R.C.E. Name = R.-S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. r� SANITATION PERMIT <br /> Job Address/Location . ....._...0!� 4105' P ta <br /> Owner ` Address <br /> ' SEPTIC TANK %CESSPOOL ❑-LEACHING FIELD' ❑ SEEPAGE PIT 11PACKAGE PLANT a <br /> } ❑ PERMANENT TEMPORARY ❑ NEW ❑ REPAIR - ❑ OTHER U ' <br /> 5. ❑ CHEMICAL TOILETS ,For July 1,-June 30, 19 ,A � � s <br /> r <br /> Type Constructl6n ; ..- Disposal Site <br /> -No. of Units Equipment Storage/Cle ning Lo ation(s) l _ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July,"June 30 <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., El <br /> More Than 1.0)60_Sq. Ft,e-> <br /> I � <br /> ❑ DRY CLEANING, Chemicals Used/AmounUMo.—�"4- J <br /> homeowner'or ticense,3 agerit'ssigrtnture rr�rti�isathe 1ellOwtng;"I ceitR?y that in the performance of the work for which this permit is issued,l sMi not employ any person <br /> in such manner as to become subject to v/vrkr,l�r's _crrpsnsatian lays of Califoa nia." t <br /> Contractor's Wring or,'sua-cant-amir,n.s n� :re �r 6 rntr-tarso ng:*"t certrfiy that in the perfbrm�e of the work for which this pernrait is issued,i shall <br /> employ persons subject1o,workmarrs•con,peasdi-1un laws of Ca.ituraia:' !. <br /> I hereby certify that I have prepared this application`And-thatthe work will be done in accordance with SJ Joaquin County <br /> �k` ordinances, state laws, and"rules and gula ns-of the San Joaquin Local Health District. E <br /> 3 j <br /> APPLICANT'S SIGNATURE X s ` ` <br /> I FOR DEPARTMENT USE ONLY <br /> f I i j <br /> Fee IS flue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i BILLING REMITTANCE $ REMIT <br /> ei BASE EXPLANATION DATE DATE I. REMITTED AMOUNT DUE CHECKED <br /> 's AMOUNT <br /> ( O <br /> FEE <br /> LESSI <br /> PRORATION <br /> —PLUS r: - - --µ•--W - �-- _ -.._ .. <br /> PENALTY <br /> OTHER ^'"'.�. � _ -,.. � �.,.. -«..----•—•�,'� � +. -., w.�,....�.--^^�- ..,...-,.t -,. .r. ..,-v <br /> j OTHER <br /> Received by Date Receipt NO. Permit No Iss ance ate Mailed Delivered <br /> F .- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES-. 1601 E.HAZELTON AYE.,P.O.Bo:20119- STOCKTON,CA 95201 - <br />