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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> y <br /> APPLICATION <br /> (For Non-Transferable yRevocable-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 /> w Business Name (DBA) F7L yD lt/r7&AsAddress. "" �`� f�7ax� <br /> Y <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a7 <br /> Business Telephone No. 49— A971 Emergency Telephone No. <br /> Contractor Licence No. - , , Yf 27 e, - <br /> L Applicants Name (Print) eLAryA - Wr ODTitle ��✓'��- Date9—P7— <br /> Please check Applicable Category(1-7)and Fill in-the Required Information �R ) <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. 'CAL. License Renewal No. <br /> Capacity Gal., Weights& Measures No. + <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD z> <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored t <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/Location o17.29 6A 1`-+wIn D,2-Lye f �7'taG.,e7'.7r✓ <br /> Owner . 1 Fe6p `S2!77 z(A6A Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING,FIELD rXr SEEPAGE PIT ❑ PACKAGE PLANT I <br /> 13 PERMANENT ❑ TEMPORARY 11 NEW 6 +,REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction F. Disposal Site _ <br /> No. of Units Equipment Storage/Cleaning L-ocation(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> 'Plant Location <br /> Plant CapacityNo. Units Served <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 = ;, a <br /> i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,_ More Than 1,000 Sq. Ft. " <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. � <br /> Nomsownerorficbnssd egent't "I certifythatirrthe performanceof the workforwhichthis omit is issued,I Shaft noIshall <br /> in such manner as to become suoject to workmarts eompeasation laws of Uiforr4.` <br /> Contractor's #d*V or sub.contracm sg: stgnsture crrtifras d+e foAewiaA:'I certify that in the performance of the work for which this permit is <br /> employ persons subject to workman s compensation laws 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 rules and regulations of the Sa ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> _ t i <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 I <br /> BILLING REMITTANCE $ REMIT - - <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> ? <br /> DATE DATE REMITTED AMOUNT <br /> FEE yr d 0 <br /> LESS 4 <br /> PRORATIONPLUS <br /> * r <br /> PENALTY <br /> OTHER _ <br /> .. OTHER <br /> EX <br /> Received by Date * fReceipt No: } Per it No. Is ance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 160T.T.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />