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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 /> ENVIRONMEN AL HE LTH,PERMIT <br /> LIQUM WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA) '. rr _ Add r ss <br /> i Owner sLV Address / ,.�Cf" N <br /> �- f <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. _ s 1 Emergency Telephone No. <br /> Contractor Licence No. <br />' a Applicants Name (Print) W. -S0 Title w Date <br /> Please check Applicable Category (1-7)and Fill in the Required-Information„ r t q f <br /> 1 <br /> PP 1 RC1 : <br /> 1. 13 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) V <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 /> 2. ❑ PUMPER YARD <br /> 41 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored t '� <br /> 3. ❑ PERCOLATION TEST i <br /> R.S. or R.C.E. Name R.S. or R.C.E- No. ,rr <br /> �t ,Location Test Date/Time <br /> U4. J SANITATION PERMIT Gtr 1 <br /> -0 Addre s/Location 1 1767S L � ` ; <br /> Owner <br /> CS 0 Address <br /> �. YF ♦ -i� <br /> I _ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PA WAGE-PLAN T It <br /> PERMANENT ❑ TEMPORARY r NEW ❑ REPAIR OTHER r�� Q <br />€ 5. ❑ CHEMICAL TOILETS- For July 1,'-June 30, 19 <br /> Type Construction Disposal Site- <br /> i 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 /> l Plant Capacity No. Units Served <br /> 7. ❑-LAUNDRY For July 1, -June 30, 19 <br /> l SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. , <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 140nte CAUMrarlicenead age+tt's 9l9natune certifies the following,'Ttertifythat in the perfo,mance;f*he woA for which this por m4k isi0sue5;;slialI not et-lct}o;,Mmy oer <br /> 10dict►manner as t0 treCerle sul?yect tri;=ror':n:s;r':com;­�nsG;;_-r tans ai Co4iforni; ' <br /> r <br /> Contractor's.tririrtg_or sub•c3n:ras:is�g ';,s,ria�+rC ceri0ies'teas 1G1."owins: "I certify that in*a performance of the work for which this petmi3 ts+ss,;etr,.f shall <br /> VVloy persons subject to workman's compensation laws of California" <br /> I 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 rules d regulatio of the S Joaquin Local Health District. Z, <br /> APPLICANT'S SIGNATE X <br /> - I FOR DEPARTMENT USE ONLY <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE rREMITTED AMOUNT DUE CHECKED <br /> s. <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION } <br /> PLUS <br /> PENALTY <br /> OTHER _ D <br /> OTHER <br /> Received by Date Receipt No. - Permit No. issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: .i;ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 5520 <br />