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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 /> s LIQUID WASTE ZZ 811~O q 0�-,C3 5' <br /> �P Aiopl ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District J <br /> F Business Name (DBA) CAJ MDo2f=''Jr Sc`ZL4Z'g ddress -Z5'_,o <br /> aOwner Z< Al ice _c— Address 67 F Jes ee—/—,)_7— A V--- <br /> Firm <br /> --Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. J c f Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date l: <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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights S 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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner 'ofV:Jf e- C.IZ 1> A.) IK Address <br /> PC 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. ❑ 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.._T <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Home ownarorlicerls2da-gent's signature rertifiesthefolloo-firq:"Ifortify t'ortirlheF^rf r, anceofthew,orkforwhIcIlIN5petmitisissucd,Ishailriaiernployany person ti <br /> in such manner as to ov f)rne subject to wonkrnan's cornpeusrltie+ {aws of Callorn:a <br /> Contractor's hi^na 's* sub-contracting siOM)tUro cErtjfje1: ¢t:' ailasr:r.�: "I certify t£iat in the perforrranco ut the work for which this permit is issued,I shall <br /> emp€oy persons 3J,bj jet t;v:.!kntan's compensahurl la%vs©f Cali;f.ia." <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 and re ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> C11 <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 Ju$y 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I/ <br /> PENALTY v �, <br /> OTHER <br /> OTHER <br /> rA ` 1 l 2-- q <br /> Received by Date 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 r <br />