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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 /> ENVIROkMENTAL 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 <br /> H Business Name (DBA)LZAgI�I(��I� 44IZEEP, GO't.1,5T -CO! Address-�L2Qi 'a: F»F1�!\OYaT ST. <br /> z Owner RAqAAs' MD Address - I'50"3 ��"E1N G�,IyL's2p <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a5 Telephone No. 5--72-7 .Emergency Telephone No._ __ + <br /> Contractor Licence No. � <br /> L Applicants Name (Print) Rffi MO KID (DIZF. E� Title oW m F 2 Dates CO) ED1!132- <br /> Please <br /> 32Please check Applicable Category(1-7)and_Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t <br /> For July 1, June 30,19 - Disposal Sites - - <br /> Description(Make/Yr., Color) _ _- <br /> Serial No. CAL License No. f t' CAL License Renewal No. <br /> Capacity Gal.,Weights & Measures NoT' -" ;-• - _ ! <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, _ June:30, 19 ) �` <br /> No. of Vehicles Storedf <br /> { <br /> No. of Chemical Toilets Stored ! } <br /> 3. ❑ PERCOLATION TEST } r <br /> R.S. or R.C.E. Name f R.S. or R.C.E. No. } <br /> Test Pcation "t - Test Date/Time } <br /> 4. SANITATION PERMIT <br /> I <br /> Job Address/Location- <br /> ner [( Address _ <br /> SEPTIC TAN.K,,.t CESSPOOL- `� ❑''LEACHING FIELD 1:1SEEPAGE PIT ❑ PACKAGE PLANT <br /> i <br /> KPERMANENT ❑ TEMPORARY. ❑{NEW 'ti ❑ REPAIR E] OTHER _ <br /> 5. E] CHEMICAL TOILETS For July 1, -June 30, 19 r' ' <br /> Type Construction ` Disposalt_�Site 4 - j _ <br /> No. of Units ti Equipment'Storage/Cleaning Location(s) ~c •�t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r <br /> Operator Name --�I'�--=�- - --W^ Where Certified <br /> �r. _ <br /> Plant Location <br /> Plant Capacity 1-s No. Units Served ��_4. * ` r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19' I l -OT7f <br /> F <br /> SIZE: ElLess Than 1,000 Sq: Ft.,' ElMore Than 1,0 <br /> 0 <br /> 0 <br /> Sq. Ft f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/M07­7_. <br /> Home owneror licensed agaim's signature eertifiaetheiollawfng:"I certify th:1t!n the perforinaneeof the wvork fnr wl!ich this permit is issued,I shagl not employ any person, <br /> in such manner as to trecome sub;oct to Yvurklnar's cornpensatior,laws ref r,tjt re>:t. , <br /> Contractor's hiring or sub•cimlrac1ing signature cer ties •1he foito%wing: s certify l~at in the perlormance o1 the,vork for which this p.�f f is issued,I shall <br /> employ persons subject to vworkmans eompensationilaws ut Califorisia." <br /> hereby certify that I have prepared this`application and that the work will be'done in accordance with San Jo uinCounty <br /> ordinances, state les and regula ioRrtof)the San Joaquin Local Health District. r <br /> { i tf+ <br /> APPLICANT'S SIGNATOR X 9�/ <br /> a <br /> bIV C <br /> F <br /> 1 � <br /> - t <br /> = FOR DEPARTMENT USE ON Y _ <br /> t <br /> Fee IS Due: 1.1 ANNUALLY ❑ PER UNIT!- 1 ❑ PER SITE';-' C1 EACH' ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 r <br /> I BILLING REMITTANCE g REMIT <br /> -BASE EXPLANATION DATE - PATE REMITTED AMOUNT DUE CHECKED <br /> } t AMOUNT <br /> FEE <br /> -1 t <br /> LESS ° <br /> 'PRORATION <br /> PLUS <br /> PENALTY .w ,�.Y� R' e- '`'F —: '-~# .t 1 <br /> OTHER ^..� fes" `�. . . <br /> OTHER <br /> eceived 4y D `ate ,Receipt No. Permit No� = Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL-HEALTH PERMIT/SERVICES " -- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />