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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 /> OF Business Name (DBA) bA.° �r?i'� � Z)t4S,�i�„2�Address <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. �`f�ii� �' fia(Y'7 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants NamTitle Date —87 <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 iii Measures No. < <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARDS <br /> For July 1, 'JUrle80,119 <br /> No. of Vehicles*Stordd` <br /> No. of Chemjcal Toilets Stored - <br /> 3. ❑ PERCOLATION TEST t <br /> R.S.or R.C.E. Name R.S. or R.C.E. No, <br /> Te Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location SUT -0 <br /> Owner !3 Y-L-)&A, fir” Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD WSEEPAGE PIT ❑ PACKAGEPLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW I REPAIR ❑ OTHER - <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> 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"" _s <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ' <br /> HOMeownerorlicensed agent's signature"rtiflesthe foitow. "I erti# i;,"";i r..; n R�`il1C :ar" rr ;:';c;t tis permit is issued,Ishallnatemployan� .c <br /> in sash manner as to become subject lo workman'S compensation ErIYlS fit Calif axrr.� <br /> Contractor', Hiring or sub-contracting .signature certifies the certify tlTai 1R following; "i tf10 0f the pCrfon t3nCe c4'p k for 4vhiC11 this permit is issued,I sil: <br /> employ persons Subject to workman's compensation lays of Califorria." <br /> hereby certify that I have epa_red this application and that the work will be one in accordance with San Joaquin County <br /> ordinances, state laws, an les nd regulatio of the San Jo Local H Di t;' <br /> APPLICANT'S SIGNATURE X \\ <br /> FOR DEPARTMENT USE ONLY V <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION D-` AMOUNT DUE CHECKED <br /> DATE DATE REMITTE . <br /> AMOUNT <br /> FEE $' <br /> LESS <br /> PRORATION <br /> PLUS v-7 71 <br /> PENALTY v <br /> OTHER - .. •• f) <br /> !/ <br /> OTHER ,. . � 3 it r i_.r' 'Tj <br /> Received by Date Receipt No. Permif No. Issuaptce Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16D1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />