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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 Joaquin Local He th District / <br /> w Business NamekBA)_M : t7L ,7:4* 7G. lb,$Ati�Aa arm Address _ G 7 Ame-L- 4ZO <br /> aOwner Address . . - 9,0!9!Il4A�� <br /> Firm Partners, Addresses and Tele hone Numbers <br /> IL Business Telephone No. Emergency Telephone No.4-:5 •�i1R+y►+G� <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title, Date A-41r—gft <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 & 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 w <br /> Jab Address/Location .l ZL./ Q�.�. „"C.A_ oe, ,m=aL.L o1ia_ <br /> Owner 01 :of A* �` G /-n0 t.r all C-A i? Address +` <br /> SEPTIC TANK, ❑ CESSP001 LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT { <br /> CKPERMANENT ❑TEMPORARY• -❑`NEW ❑ REPAIR ❑ OTHERS <br /> 5. C] CHEMICAL TOILETS For July 1, -June 30, 19 Y r ' a <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s)" l <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1 I <br /> Operator Name a Where Certified <br /> Plant Location t Y <br /> Plant Capacity _ 4- No. Units Served <br /> 7. ❑ _LAUNDRY For July 1, -June 30, 19 max. + <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More.Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowner orlicansedagent's Signatur ertifiasttlefoliawing;"I certify thatitttheperformanceoftheworkforwhichfhispermitisissued,Ishallnotemployanyperso0 <br /> in such manner•as to become subject til workman's rompensatior laws of California." <br /> Contractor's hiring or sub-eontractirm utgnature certifies t". following: "l certify that-in the performance of the work for which this permit is issued,;Shall <br /> employ persons subject to workman's tompestcatiutr'avis of California. { <br /> hereby certify that I have prepared this application and that the work.will be done in accordance with San Joaquin County # <br /> ordiriances, state laws, and rules and regulations of the San Joaquin,Local Health District. 1 <br /> APPLICANT'S SIGNATURE X <br /> r <br /> e 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 /> # r BILLING''' REMITTANCE $ REMIT 1 <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> .. - DATE ')ATE REMITTED AMOUNT <br /> lipI <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS r Y 1 <br /> PENALTY <br /> OTHER e U L <br /> to <br /> OTHER, <br /> 91z? It -7 1 G 3-z <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 <br />