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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 /> Applicati� I�,on is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA)Y A tP_4-S4-�T QI� C Address( <br /> aOwner Address <br /> Firm Partners, Addresses and Telephro+nee Numbers <br /> aBusiness Telephone No. Emergency Emergency Telephone Na <br /> Contractor Licence No. ZSl � <br /> aOv <br /> L Applicants Name (Print) S—=,hA L_'t-y I E�' , ASI S Title "MA6EER Date <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 UJI <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 <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 L cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location 1. 4 t sI Q _� <br /> Owner Mwf✓ Cz1 I LOl4 Address 15�6-77 ' )am Aa CA 9ti1.810 <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑jj SEEPAGE PIT ❑ PACKAGE PLAN <br /> �� <br /> PERMANENT ❑ TEMPORARY ❑ NEW tel-REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <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 /> Home owrlar or licensed agent's signature csrtiflesthe following:"i certify that la the perform ar:c^Df the work for which'this permit is issued,I shall not employ any person <br /> in such man ier as to become subject to workman s compensation;laws of cahfom i ' <br /> Contractor's hiring or sub-contracting signature certifles the foriowing: "I certify that in the performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation laws of California." <br /> I hereby certify that,I hav prepared this application an that theXqrk will be done in accordance with San Joaquin County <br /> ordinances,state laws, rules and reaulptions of t n�ocalAqealth District. <br /> APPLICANT'S SIGNATURE X <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE -.CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE q <br /> LESSi d <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ,S a7 <br /> Received by Date Receipt No. Pennif No. .ssuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />