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e. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> " - ..- - i APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL_ HEALTH PERMIT <br /> ."sem1 LIQUID WASTE <br /> rx i" Applicati 'ri"is hereby ma to car n busi ess" the jur'sd' tional area of th an oaquin Local Health District <br /> H Business Name (Dl3A)' L L� ddress <br /> Ca Owne `-�— Address' <br /> 9 Firm Partners, Addresses anqRgfione Numbers - <br /> aBusiness Telephone No. 1 Emergency Telephone No. <br /> Contractor Licence No. <br /> ApplicantsL <br /> ,Name:(Print} - `F� - Title,, 31 e , <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> g 1: 13_PUMPER VEHICI:E PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,- June-30, 19 ( - Disposal Sites -- <br /> . J * �t-fit s .t �- r <br /> Description(Make/Yr., Color) C- <br /> � -- � "`- <br /> Serial No. ( CAL. License No. r r --s CAL. License Renewal No. t <br /> Capacity —Gal—.,,Weights &-Measuies No. r ":— <br /> Equipment Parking Address <br />' 2. ❑ PUMPER YARD <br /> 1 ~~ <br /> For July 1, " June 30, 1.9-�-" <br /> No.of Vehicles Stole-d" <br /> No.of Chemical Toilets Stored <br /> 3. 11PERCOLATION TEST <br /> R.S.°or"R.C.E. Name, _ �..r .t' R.S. or R.C.E. No. <br /> Test Location Test_Datejime <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> S S f <br /> Ow er. ` X`'E EE�` �'' Address <br /> SEPTIC TANK" ❑ CESSPOOL-.' 'EACHING-FIELD . -0-SEEPAGE PIT. PACKAGE PLANT,.J <br /> U PERMANENT C TREPAIR ;f �s[]tOTHER y <br /> 5. ❑ CHEMICAL TOILETS For July 1,-Jurie 30',19 <br /> Type Construction =.Disposal Site f k <br /> No. of Units Equipment Storage/Cleaning Locations) "- C <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 # <br /> Operator Name sl� -=- Where Certified- <br /> Plant Location I ti t <br /> Plant Capacity Y No. Units Served <br /> 7. 13 LAUNDRY For July 1, -June 30, 19IW✓ ", =mss , <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DFW.Ax"&W%" 11ged/Amoun . <br /> tial nmireCa thefatlewkig:1cerltitrtttattnthe perfomanceoftheworkfor whiEhthis.permit isissued,l$hallnot empioyany person <br /> in such m~astg become 5ubJ9cE to wnrkman'S C0mpe1"atio0 taws of Catilnrn;l.' <br />' Contracter's fil13nQ or aub-contraeting signature ee.tHies the fotabrAririq: 3 certiftl that in Ite performance of the work for which this permit is issued.I shall <br /> empfay PWSQns Subject to Workman's compensation law6 of Catitornla." <br /> herebeztLfyY-cthat I have prepared is application and that the work will be done in accordance with San Joaquin County <br /> ordinances, sta��la rules and re Lila ns t e San Joaquin t <br /> Local Health District. <br /> APPLICANT'S SIGNATURE X. <br /> �. FOR DEPARTMENT USE ONLY _ - - ; <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT' ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &,Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> ' - - DATE. - - DATE REMITTED AMOUNT i, <br /> 4 <br /> LESS r fi X f-"'• �.i <br /> PRORATION ° <br /> PLUS <br /> PENALTY x - <br /> t <br /> OTHER" - <br /> OTHER <br /> Received-by ate 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 />