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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign'The'Applicatlan. i <br /> APPLICATION r <br /> (For Non-Transferable,` Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT k <br /> LIQUID WASTE <br /> Applicatiorl Is hereby made to car on business in the'jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA)D,A- AZ IS14���IJ� ="C, , Address]?-0.&2i 4•S; ��.!) O � z,Q J <br /> aOwner Address <br /> J Firm Partners, Addresses and Tele hone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) f AA —Title Title Date <br /> Please check Applicable Category (1-7) and Fill In the Required Information x Y <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 y <br /> 2. ❑ PUMPER YARD }�'' " tr <br /> For July 1, June"30, 19� & ,� <br /> No. of Vehicles Stored r <br /> No. of Chemical Toilets Stored - <br /> t e <br /> 3. ❑ PERCOLATION TEST ••- <br /> R.S. or R.C.E. Name { 1 :�' R.S. Or R.C.E. No. ; <br /> Tet cation `s:, w Test Date/Time f <br /> 4. SANITATION PERMIT' ` • '` f <br /> Job Address/Location t'3'�a7 �1�?�P �' use . �—,Pz-? �' J <br /> O ner Addre �� <br /> SEPTIC TANK ' ❑ CESSPOOL- LEACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANENT ❑-TEMPORARY.,, VNEW i ❑ REPAIR ❑ OTHE <br /> 5. 11 CHEMICAL TOILETS For-July 1,"-"June-30;t19 __ <br /> Type Construction dP` Disposal Site <br /> No. of Units - s Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT i For July 1, -June 30, 19 # <br /> Operator Name "'*}-.T _ I Where Certified <br /> Plant Location J. A JJ <br /> Plant Capacity �.i No. Units Served •' <br /> 7. ❑ LAUNDRY For July 1, -June 30,19 <br /> SIZE: ❑ Less Than 1,000 Sq 'Ft,,.-_,.1❑'More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/A mount/Mo- <br /> ttomeowner o■licensadagent's al gnatureeertifiesthe foilowing;°'I certify that In the performance of the work for which this * <br /> in Stich manner as to become subject to woekman,s compensation laws of Catifarnia" permit is issued.l shall noiemplay any parson r <br /> Cbntreetnr s hiring or sub-contracting signature certifies the following: 1 sertify that in the performance of the work Tor wbir:I.this permit is issued,Ishan <br /> employ persons subject to workman s compensation taws of California," t t <br /> I hereby certify that I have repared this application and that the work will be done in accordance with'San Joaquin County <br /> ordinances, state laws, an a and regula ' sof th n Joaq Focal ealth District. <br /> 1 r r <br /> APPLICANT'S SIGNATURE X <br /> t FOR DEPARTMENT;USE.ONLY,•,4 r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT:- ❑ PER SITE ❑ EACH ❑ January 1 &Received_By January 31 ❑ July 1 &Received By July 31 <br /> rt. <br /> BILLING REMITTANCE $ REMIT <br /> _-BASE EXPLANATION DATE PATE REMITTED AMOUNT DUE CHECKED <br /> r AMOUNT <br /> FEE 5 8 O O <br /> Y <br /> LESS 4 <br /> PRORATION <br /> PLUS <br /> r <br /> ^� PENALTY <br /> OTHER y 1 <br /> - ' t # <br /> OTHER _ <br /> 7 t 3 <br /> Received by - Date -Receipt No. Permit No Issua o to Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES'TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HA - AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> r-.t <br />