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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 ' h9rreby m de tg carryQn,,business in the jurisdictional area of the S Jo w Local H Ith Di trict <br /> r ,F Business Name DBA) ►'l +- -Crt�✓�Q� Address ��6 � S ✓Z( <br /> aOwner--/, Address 0 <br /> Firm Partners, Addresses and Telephone Numbers 61 161 <br /> aBusiness Telephone No. IN.. Emergency Telephone No. <br /> Contractor Licence No. r/b Woo 4?J`Z 76 <br /> Applicants Name (Print) G �. K h *�Title Q W Q Date f <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) l <br /> For July 1, June 30, 19 Disposal Sites rr <br /> Description(Make/Yr.,Color) - ^i-- <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights&Measures No. f .1 <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. ((SANITATION PERMIT <br /> Job Address/Loc tion z6 0 t•� <br /> Owner MIOCKU&At ✓W1'P—T ,. 'Address 6 - .s <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT, <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 4rZ REPAIR OTHER 'AM1176AJ <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> 01, <br /> Type Construction Disposal Site . -4 <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 Served" <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowne►orficensed ager,Ys six,na Ace *,ecthe#otlowing.-"!cert fy thmir,fbe p-r',rriar:ce of tho work f,r vt ch this Kermit is issued,I shah not employ any person <br /> in such manner as to b come sub'e °a rk;=, <br /> f ,t;pe ns lien is ws a, <br /> Contractor's hiring t t suorkma 's cog SignatftP6 erig7ies tl:e t'oRow wing: "1 certify that in the Ncrt to rk forwhl ;;is'permit is issued,I Shall <br /> employ persons subject to workman's compersatiun laays of California." <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 ules nd re lations of Ape San J quip LocHealth District. <br /> ^ <br /> APPLICANT'S SIGNATURE X <br /> ,lza- <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 /> BASE EXPLANATION BILLING REMITTANCE $ i REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE I-S ». <br /> LESS <br /> PRORATION <br /> PLUS i t <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by I Datd Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES t801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />