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't Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable Revocable,-and Suspendable) SEPTAGE <br /> 'y Y ENVIRONMENTAL HEALTH PERMIT <br /> T LIQUID WASTE <br /> Applicati is hereby de t carry n busies in# .unsdictional.area of th a. Joa n Local Health District <br /> ,F Busine arae (DBA) Address <br /> a Own : Address <br /> IF <br /> Firm Partners, Addresses and I' ph ne NNu,m errs <br /> aBusiness Telephone No. Emergency Telephone No., <br /> Contractor Licence No.. (i <br /> Date <br /> Title <br /> Applicants Name,(Print). r " . c '' VV <br /> Pleas e'cFieck Applicable;Cate ory{1-7)-and Fill in the Required Information ,0 <br /> v <br /> 1:--0 PUMPER,VEHICLE PERM REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,°19 N = - Disposal Sites - <br /> f4 <br /> Description Make/Y,r 7Color).' 41 v' <br /> \( '� E J CAL. License Na. CAL. License Renewal No. 1 <br /> SePial_Noy ^ <br /> Capacity ' Gal., Weights & Measures No. <br /> Equipment Parking Address 161, <br /> 2. ❑ PUMPER YARD`s '; A_-r <br /> For July 1, -June 30, <br /> -cry, iY r i <br /> No. of Vehicles Storedi <br /> No. of Chemical Toilets Stored F• i <br /> 3. ❑ PERCOLATION TEST <br /> s r R.S.or R.G.E.No. <br /> R.S. or R.C.E. <br /> - <br /> Test Location i r r ft Test Date/Time <br /> 4. ISANITATlON PE �lT �__�A <br /> .V � I V <br /> y� n1` <br /> Job Addre L ation • <br /> Owner dress <br /> ❑ SEPTIC TANK C1 CESSPOOL ?,--[1-LEACHING FIELD t�SEEPAGE PIT 13 PACKAGE PLANT <br /> I✓rPERMANENT�: E) TEIV PtI R�RY'1 11"NEW 'REPAIR ❑ OTHER <br /> r w.. - <br /> 5. ❑ CHEMICAL TOILETS Fr.July,1,-.June 30, 19 5' <br /> F Type Construction J 47 9 } Disposal-Site <br /> No. of Units t -=Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT LANT For-July 1, -June 30, 19 <br /> Operator�Name'' 4 I = ! �' Where Certified <br /> Plant Locations _ <br /> Plant Capacity'" %,N. Units Served u <br /> 7. ❑ LAUNDRY - For July 1, June 30, 19 <br /> I ' <br /> SIZE: ❑ Less-Than 1,000 Sq. Ftp; ❑ More Than 1;000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. <br /> Home owner orlirnnsad agent s sig4ei'ure certtfie s the following:"t rerl if}that*n th a perfa rmanee of Ihewnrk for which this permit is isslsed,i shall not employ any perse l <br /> in such manner as to become subjecrt to warkman's compensation laws of Ca itomia." ; <br /> Con"Ctor's hiring or sub-contFactinq signature certifies''t4e folk vying:"1 certify that in�he performance of the work for which this permit is issued,I shall <br /> employ,persons subject to workman s compensation laws of California.""'" <br /> k' I hereby certify that.'I have prepared this application ah$that the work will be done in,-accord`anc'e-with San Joaquin County <br /> Ord inances,'state laws, and r es and regul sons `f the San Joaquin;Local Health district' <br /> APPLICANT'S SIGNATURE— <br /> � _ <br /> Y ¢ � FOR DEPARTMENT USE ONLY <br /> e <br /> Fee.IS Due: 11ANNUALLY i❑APER UNIT ElPER SITE —❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING 17, <br /> ',kR <br /> r.E <br /> .M <br /> ITTANCE $ _ AMOUNT DUE CHECKED <br /> EXPLANATIONBASE DATE REMITTED. nV <br /> 9r w DATEAMOUNT <br /> R <br /> FEE � <br /> LESS <br /> PRORATION p <br /> PLUS J` <br /> PENALTY SII! <br /> OTHER <br /> OTHER <br /> i <br /> Received by - Date Receipt No. Permit No. suance ate Mailed .-� Delivered:' <br /> ON AVE. P.O:t3a■2009 STOCt(TON;CA-95201 <br /> —_­APPLICANT—RET6RN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESHAZECT -- - <br />