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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> n (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 /> y Business Name (DBA)DQ•� P-�IS� �-����`-?C. . _Address :� ! 4 1» <br /> z Owner- -Address Y v <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No: -7--- - Emergency Telephone No <br /> 1 <br /> Contractor Licence No. <br /> a Title MdL ) � 7� Date 7� <br /> L Applicants Name (Print) T 1 r,, <br /> Please check Applicable Category(1-7)and Fill in the Required Information r xY , W <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <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 /> a 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/LocationCA <br /> rC' <br /> Owner V I 5 Address SmAhl <br /> , <br /> i SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ._ <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER [� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment.Storage/Cleaning Locations) <br /> 6. I] PACKAGE TREATMENT PLANT For July 1, -June 30, 19 -�• <br /> Operator Name Where Certified <br /> Plant Location <br /> ` Plant Capacity. i No. Units Served Y <br /> ' 7: ❑ LAUNDRY ''For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.;Ft. T <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Homeowner or licensedegerlt's "I certify th?tiPttwPerfi nariLO{1f''Meijmorktarvillichthispermitisissued,tstaallnotemployattyperson <br /> in such manner as to'become subject to workman's compensation lay-m, of Cakfnf--,: <br /> Contractor's hiring or sub-centtacting signature cerWiss tiro fai}owing: "I certify lira,i;t fie performanLe of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation lays of California." - <br /> I hereby certify that I have repared this applidation and that the work will be done in accordance with San Joaquin County <br /> } ordinances, state laws, an r les and reguiat' s of the 5 aquin Loc ealt�District. <br /> APPLICANT'S SIGNATURE X <br /> a . . _ 0q <br /> FOR <br /> ` r FOR DEPARTMENT.USE ONLY <br /> w ;t <br /> Fee IS Due: 11ANNUALLY ` '❑ PER.UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 Received By July 31 <br /> REMIT <br /> •a.,,_ BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE V <br /> LESS Y <br /> PRORATION- <br /> PLUS i <br /> PENALTY <br /> OTHER <br /> OTHER .> # <br /> * _ <br /> 1�5"q 7 /LAI f <br /> Received by Date •Receipt No. Permit No. ss nce ate Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boar 2409 STOCKTON,CA 95201 <br />