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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 /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District. <br /> .r <br /> ,F Business Name (DBA) Address <br /> c Owner /?'I E'� lU A �. Address <br /> J Firm Partners, Addresses and Tel hone Number Q -7 <br /> a. Business Telephone No. — S w. Emergency Telephone.No. <br /> _J Contractor Licence No. <br /> LApplicants Name (Print) Title � -- - 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 -T Disposal•Sites_ - - <br /> Description(Make/Yr., Color) ` <br /> Serial No. CAL. Licertse-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 Location Test Date/Time _ <br /> x 4. 1:1 SANITATION PERMIT s �c? ' <br />/K Job Address/Location / / f V �'� 's�' A �! - -- G1 Zn <br /> Owner ZA/,I In ��-/ �1 A IV , At-k— Address f'7 3 7 � ` 0�� �=5 -� l -_ C-'c '5/9 3 a <br /> SEPTIC TANK ❑ CESSPOOL El LEACHING FIELD '.❑ SEEPAGE PCfV ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ONEW ❑ REPAIR ❑ OTHER =� <br /> 5. 1:1 CHEMICAL TOILETS For July 1, :June 30, 19 <br />.� .Type Construction. �` Disposal Site __.. <br /> . l <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name . R r 'f7� ere Certified <br /> Plant Location <br /> Plant Capacity No. Units Served- <br /> 7. <br /> erve -7. © LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 13More Than 1,000 Sq.-Ft- <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 7 <br /> , <br /> Home owner oriieenzedager.,3 signnfur"crt.fict igfnttovu;r,y:"1re,W flnll1t+ pe7 <br /> ,' .m4 :C th y�'�`h.`,',li;.othispermit iSisS-Jr`,'s Ha;inot employ any pfrson <br /> in such manner as to become 5!+�je�itU;i'QrT! R'$Cu; JGiSF,:iia:??:'i: f .:81k ), .•. �� '^ { i v s <br /> Contractor's hiring or Sub-con'Prrc=ing Sig :s co:�'�frg St+r' f0itOvrin3: ,'"{ .�Itity_t;1ut IR tl";.�.. fi1l- ,ce of ii:C Yrork for which this permit is issued,I shall <br /> employ persons subject to workman's cump anon lativs ,Gai;fcrnia." - <br /> E <br /> I hereby certify that I v this appl' ti n and the s work A one in accordance with San `qU Coupty <br /> ordinances, state the San t Health District- i "° <br /> APPLICANT'S SIGNATU <br /> C) C <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE r, j7 EACH ll] Januar 1'&Received.By Januar x ❑ Jul 1 &Received B Jur 31 10 <br /> fw. ., Y__.,. Y Y., Y Y Y <br /> BILLING REMITTANCE $ REMIT - <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE -REMITTED - - AMOUNT - <br /> FEE <br /> LESS w . <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> a <br /> OTHER <br /> OTHER <br /> Received Ify Date RedeiMNO. Permit No. Issuan Mailed Delivered .. <br /> p r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES -1601 E.HAZE YE.,P.O.Box 2009 STOCKTON,CA 95201 <br />