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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignThe Application. Q <br /> ry/3 0 ,..�,v,.�.._. t <br /> c¢r - � APPLICATION <br /> ,, R (For Non-Transferable, Revocable,and Suspendab <br /> le)No to � SEPTAGE <br /> ENVIRONMENTAL <br /> A__A <br /> � <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name DBA) Addre <br /> a Owner %' Address ` �L b 'e�" T `�T= S &cAT'To Ni cA <br /> J Firm Partners, Addresses an(��Tel p one Nu bers <br /> CL <br /> Business Telephone No. ` Tz G Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date J— <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 S <br /> Description(Make/Yr., Color) n <br /> Serial No. CAL. License No. CAL.License Renewal No. 1C� <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 /> T Lo ation Test Date/Time <br /> 4e ANITATION PERMIT �e <br /> Job Address/Location 4? er 2 a�c!am- a G T4 k.;, <br /> Owner V! 4 A /_^4 Ce Arft A e0-F Address '"C 46 <br /> g SEPTIC TANK ❑ CESSPOOL 21LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 0 NEW ❑ REPAIR ❑ OTHER T <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site t <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 /> Homeowner or licensed agent's signature certifies-the following. Icet;`y Fat:n hepe.rfermanceoftheworr•.fore'rchthispermitisissued,Ishallnotemployanyperson <br /> in such manner as to become subject to workma 's cornpe at;c,,w nit <br /> Contractor's hiring or sub-contracting signature certivrs tr tnr, `i ce+ +•`,i.?t;;;,I t;tE t)efto, n.,.. : .hc,volk for which,his,,ermit is issued,I shall <br /> employ persons subject to workman's compensation laws of Califui,F . <br /> I hereby certify that I have repay d this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, stat laws, a ules d regul n the San J aquin Local Health District. <br /> APPLICANT'S SIGNATU <br /> 61 1 <br /> FOR DEPARTMENT USE <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH Iq J ary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING NCE $DATE DATE REMITTED AMOUNTbUE CHECKED <br /> AMOUNT <br /> FEE S00 <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY 40,14t� <br /> OTHER <br /> OTHER ! i _ / s <br /> Vl l <br /> Received by Cate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />