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1 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> w {O (For Non-Transferable,'Revpcable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ereby made to 99rry on business in the jurisdictional area of the San Joaquin Local Heal th_D(strict. ,.,. <br /> 1 <br /> rn Business Na (DBA) ddress �{ "9G a +.- <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers t__ <br /> a Business Telephone No. �� ��d Emergency Telephone No. <br /> Contractor Licence No. . <br /> L Applicants Name (Print) Tlkle Date f® " k <br /> t <br /> Please check Applicable'C egory 0-7) and Fill_in theRequiredInformation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f " <br /> Foi July 1; -' -June-30,>19 Disposal Sites, <br /> Description(Make/.Yr., <br /> Serial No. 4 - �b s CAL. License No. CAL.License Renewal No. <br /> Capacity -" -- -.G al:,_Weights$.Measures No <br /> Equipment Parkin <br /> g,Address <br /> i ❑ PUMPER YARD _ <br /> kFor July.1; June 30, 1'9' <br /> INo�of V.ehicles_Stored <br /> .No.1of Chemical Toilets Stored _ - - <br /> 3. ❑ PERCOLATION TEST ---(•- --4 -- � <br /> R.S. or R.C.E. Name I R.S. or R.C.E. No. <br /> Test.Lation Test hate/Timet <br /> 4. V SANITATION-PERMIT <br /> Job Addres /Location 3799 �F ' ' <br /> Owner ` 4 P Address <br /> ❑ SEPTIC TANK` ❑ CESSPOOL- ❑ LERCHING FIELD U IF G ,PIT. []*PACKAGE PLANT i <br /> ❑ PERMANENT 13 TEMPORARY ❑iNEW C9-9EPAIR 1--DOTHERI W '� <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30 19 "" : - R <br /> • i <br /> Type Construction - ?- N*bisposal Site-- <br /> No. of Units - Equipment Storage/Cleaning Location(s) e <br /> 6. ❑ PACKAGE TREATMENT PLANT_ For Ju iy 1-�Une 30 +19� F "s 66 <br /> Operator Name r ` 1 Where.Certified: <br /> If Plant Location "' <br /> -Plant Capacity No. Units Served .1• l y j <br /> 7. ❑ LAUNDRY For July 1, -June 30,-19 <br /> C1SIZE: Less Thanq.1.000 Sq. Ft., ❑ More Than 1,000 SFt. <br /> �- -� a <br /> '0 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Nome owner orumnsedagent's signature eertWwsthe following:"Icertify!hatinThe Re ormaanceofOle work for*htbthisilermit-fs#SsueA,lshr lraft"emplayany person <br /> in Such matmer as to become subject to workman's com;tmnsation Fans of Cali#erni�._' , <br /> Contractor's hirir►@ or sub eoatreeciseg dfynasute eery the iottiwin wlCertify-ttrat•in•the performance of the Work for wttich ibis permit is issued,I shall <br /> ` employ persons sublaet tQ wofkmaris compensatioo laws of California.: <br /> I hereby certify that I have prepared this application and that the work will be done in accord nce with San Joaquin County- <br /> ordinances. <br /> ountyordinances, state laws, a rul and regulations o e San Joaquin Local Health District. C,�` <br /> r APPLICANT'S SIGNATURE tt <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 /> BILLING REMITTANCE $ REMIT <br /> RASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE . REMITTED _ ." AMOUNT <br /> s. FEE $AS <br /> LESS f 4– <br /> - <br /> PRORATION – —k <br /> PLUS y " <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. 5 Isstprice Uate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: _ENVIRONMENTAL HEALTH PERMIT/SERVICES` 1601'E:HAZELTON AVE:,P:O,Box 2009 STOCKTON,CA 95201 - <br />