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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 /> ENVIRONMENTAL 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) =Ad V D Er .itllae Rnb Address /7-Y" A A",644 S2; S7zRey -"0L1 <br /> i Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 44&S- 397/ Emergency Telephone No. <br /> Contractor Licence No. 4-7---c;;i7 <br /> L Applicants Name (Print) F-14 YD 957, Ak-14-P Title 9:?4A17;e, Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Colo) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <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 R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. 4 SANITATION PERMIT <br /> Job Address/Location 3 a .4S,444-51Y 44AAW s YraG,C77 t/ <br /> Owner C'&AAhV,6 X27-S a 4e Address 73 <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW 1K REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 W <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Servet) <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 0 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Hameowneror1i1ffyythifMtheperformanceottheworkforwNichthispermitisissae6,IshaliAotemployanyperson <br /> in such manna as to 60cptts!subject to workmaa's comperLsatien laws ofCaNternia.' <br /> Contractor's hb" w ef9nasi cordes Ills A certify that in the perforrrlance of the work tot wftkh this permit is issued,I shall <br /> amploypersons subject towerkrna'stomp risativnUmsatCaWorni&, <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNAI06REX <br /> FOR DEPARTMENT USE ONLY <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 CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE C <br /> LESS <br /> PRORATION f� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �� _ 14 - �- - <br /> Received by Date Receipt No. Permit No. Issua e D e ailed ro <br /> De ered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZ AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />